PUBUC 
HiALTH 
LIBRARY 


The 'New    Public   Health 


BY 


HIBBERT  WINSLOW  HTLL, 

M.  B.,  M.  D.,  D.  P.  H. 

Director:    Institute  of  Public  Health, 
London,  Ontario 

Late  Director:    Division  of  Epidemiology, 
Minnesota  State  Board  of  Health 


^[^ 
^^f^ 


First  published  as  a  series  of  eleven  monthly  articles 

by  the  Journal-Lancet  of  Minneapolis, 

under  the  auspices  of  the 

Minnesota  State  Board  of  Health 


MINNEAPOLIS,  MINN. 

PRESS  OF  THE  JOURNAL-LANCET 

1913 


PUfiLlO 
KlALTfl 


PREFACE 

The  Problem. — Until  such  time  as  poverty  is  abol- 
ished, or  the  State  takes  charge  of  children,  the  major- 
ity of  the  women  of  the  race  must  continue  to  rear  the 
majority  of  the  children  of  the  race  inadequately,  in 
homes  too  small,  without  facilities,  doing  for  them 
somehow,  individually  and  alone,  that  which  three 
women    could    hardly   do   well,   working   together. 

This  is  not  wholly  a  slum  problem  nor  is  it  a  prob- 
lem of  the  rich.  Numerically  the  race  is  chiefly  middle 
class,  neither  rich  nor  extremely  poor,  judged  by  or- 
dinary standards.  This  is  the  problem  of  the  family 
with  an  income  below  $3.ooo,  i.  e.,  it  is  the  problem 
of  the  race  proper,  and  it  is  the  old  problem  of  the 
pre-mosaic  Hebrew — how  to  make  bricks  without 
straw — alas,  often  without  knowing  how  to  make 
bricks   at  all. 

The  problem  as  a  whole  involves  food,  clothing, 
proper  physical  development,  morals.  education, 
amusement,  discipline,  and  citizenship.  But  the  public 
hygienist  has  as  yet  but  indirect  concern  with  these. 
The  public  hygienist — the  "board  of  health  man" — as 
yet  concerns  himself  chiefly  and  by  general  expecta- 
tion and  consent,  with  the  grosser,  more  imminent, 
more  spectacular,  more  immediately  tragic  problems 
of  disease  and  death,  and  chiefly  with  only  one  group 
of  these,  the  infectious  diseases.  However  much  in 
ordinary  life  over-crowding,  lack  of  facilities  and  over- 
burdening of  mothers  may  render  unavailing  even  the 
tears  and  ageing,  the  back-ache,  heart-ache,  crooked 
fingers  and  wrinkled  faces  of  mothers  striving  for 
their  young,  ten  times  over  is  the  effect  of  these  seen 
when  disease  enters  the  family,  adding  its  burdens, 
its   sorrows,  its   disabilities  and  its   deaths. 

Once  more,  remember  this  is  not  in  the  slums 
alone,  nor,  numerically,  chiefly  there.  It  is  found  in 
city  and  country,  village  and  town,  everywhere,  the 
overburdening  of  mothers,  in  ordinary  life,  added  to 
ten   times   over  when    disease    springs   up. 

How  Big  A  Problem  Is  It? — Call  the  population 
of  the  United  States  80.000,000.     Remember  that  sooner 


281706 


or  later,  every  member  of  each  generation  suffers 
from  at  least  one  infectious  disease,  often  from  two. 
three  or  four,  and  it  is  clear  that  every  generation 
suffers  anywhere  from  8o.coo.ooo  to  240.000.000  at- 
tacks of  infections.  Each  generation  pays  out  at  least 
eight  billions  of  dollars  for  this  running  of  the  gaunt- 
let, not  to  speak  of  the  disability  and  death  of  those 
who  run  it  successfully.  Tuberculosis,  diphtheria, 
summer  diarrhea,  scarlet  fever,  measles,  typhoid  fever, 
whooping  cough,  chickenpox.  to  name  onl}^  some  of 
those  best  known  to  the  laity,  how  much  sorrow,  dis- 
tress, poverty,  how  much  "making  of  none  avail"  of 
mothers'  hopes  and  prayers  and  wearing  effort  have 
these  caused!  Yet  so  common  are  they  that  "chil- 
drens'  diseases"  are  looked  upon  as  a  necessary  stage, 
almost  a  joke.  Indeed  some  people  deliberately  ex- 
pose their  children  to  them,  "to  have  it  over  with!" 
Yet  who  bears  the  burden,  the  sleepless  nights,  the 
extra  work,   the  hope   deferred? 

Ninety-five  per  cent  of  the  infectious  diseases  are 
nursed  at  home  by  mothers.  Next  to  the  children 
themselves   the  ones  who  suffer  most  are  mothers. 

Who    Keeps    the    Infectious    Disease    Going? — Once 

more  the  answer  i>  —  and  mo.-t  emphatically  — 
women  in  general  but  chietly  after  all  the  mother. 
To  be  sure  there  is  every  excuse  for  the  mother, 
— overwork,  overcrowding,  lack  of  facilities,  above 
all  ignorance  and  misdirected  training.  "misin- 
formation piled  on  lack  of  any."  But  with  all  the 
perfectly  good  apologies  stated  and  all  the  excellent 
good-will  and  effort  counted  in.  the  fact  itself  remains, 
that  mothers  propagate  and  keep  alive  and  spread  the 
infectious  diseases  of  children  more  than  any  other 
one  body  of  people,  and  that  while  conditions  remain 
as  they  are  they  must  learn  the  "rules  of  the  game" 
and  follow  them,  for  no  amount  of  coaching  or  effort 
from   the   sidelines   can   d^   more   than   help.  • 

Why  and  How  Are  Women  Responsible? — Because 
mothers  are  doing  the  work — women  in  general,  but 
chiefly  mothejfs.  The  farmer  is  responsible  (apart 
from  floodr  drought,  storm  or  other  "acts  of  God") 
for  whatever  happens  to  the  crop  from  seed  to  market. 
Women  in  general — but  chiefly  mothers — are  the 
"raisers"  and  "crop-handlers"  of  the  largest,  most 
\aluable,  most  expensi\e  and  most  difficult  crop  in 
the  country.  What  happens  to  this  crop  between 
birth  and  sixteen  years  of  age  is.  chiefly,  what  women 
do  to  it.  or  at  least  do  not  prevent.  For  the  first 
5.000  days  of  the  years  of  the  life  of  each  generation. 


(apart  from  flood,  drought,  storm  or  other  "acts  of 
God")  for  whatever  happens  to  the  crop  from  seed 
to  market.  Women  in  general — ^but  chiefly  mothers 
— are  the  '"raisers"  and  "crop-handlers"  of  the 
largest,  most  valuable,  most  expensive  and  most 
difficult  crop  in  the  country.  What  happens  to  this 
crop  between  birth  and  sixteen  years  of  age  is, 
chiefly,  what  women  do  to  it,  or  at  least  do  not 
prevent.  For  the  first  5,000  days  of  the  years  of 
the  life  of  each  generationTlthe  race  is  fed,  dressed, 
undressed,  washed,  comb^^cuddled,  kissed,  praised, 
blamed,  led,  driven,  coaxed,  taught,  spanked,  bossed 
and  otherwise  "brought  up"  by  women — women 
mothers  at  home,  women  teachers  at  school.  It  is 
chiefly  during  this  time  of  tutelage  and  supervision 
by  women  that  children  receive  their  infections;  it 
is  during  this  time  that  the  race  runs  its  gauntlet, 
dances  its  little  dance  with  death — and  pays  ten 
billions  for  it. 

Present  Attempts. — To  teach  women,  girls,  pro- 
spective mothers,  that  they  may  practice  in  their 
households,  and  in  turn  teach  their  children  to  war 
on  invisible  germ-foes  is  one  of  the  functions  of 
public  health  bacteriology.  Only  in  the  public 
schools  can  it  be  taught  with  emphasis,  weight  and 
uniformity  enough  to  impress  the  masses.  Only  if 
taught  in  the  grades  can  it  be  counted  upon  to  reach 
the  masses.  Less  than  1  per  cent  of  the  population 
reach  the  university,  only  10  per  cent  reach  the  high 
.schools.  The  great  mass  of  the  mothers  of  the 
coming  generation,  of  the  whole  race,  the  mothers  of 
more  than  their  average  of  children,  are  receiving 
grade  school  education  only.     Need  more  be  said? 

The  infectious  diseases  in  general  radiate  from 
and  are  kept  going  by  women.  Women  must  learn 
to  break  up,  divert,  stop  in  some  manner — in  every 
manner — the  exchange  of  infected  discharges 
amongst  children  at  school  and  amidst  families  at 
home  if  infectious  diseases  are  to  be  abolished  or 
abated  under  present  conditions.  The  needful  in- 
formation, beliefs,  technique  and  habits  cannot  be 
had  or  established  except  by  studying  the  basic 
principles  of  public  health,  and  this  must  be  taught  in 
the  grades  of  the  public  schools  if  it  is  to  reach  those 
who  most  need  it. 


Radical  Changes  in  Social  Conditions  the  Real 
Solution. — If  (as  cannot  be)  every  girl  now  at  grade 
school  could  be  thoroughly  taught  all  that  a  trained 
nurse  knows,  theory  and  practice,  the  best  to  be 
hoped  is  that,  becoming  a  mother,  ten  to  twenty 
years  hence,  she  may  remember  enough  to  care  for, 
if  she  have  the  facilities,  the  first  case  of  infection 
in  her  household  without  permitting  its  spread  to  the 
other  members  or  to  outsiders.  Alas,  not  one  third 
of  the  girls  will  remember,  not  one-tenth  will  have 
the  facilities.  Above  all  what  shall  be  done  in  that 
intervening  ten  to  twenty  years?  Lectures,  writings, 
sermons,  appeals  to  mothers'  clubs,  university  exten- 
sions, moving  pictures,  all  the  publicity  that  can  be 
had  or  hoped  for,  will  not  suffice  to  teach  technique 
to  the  mother  now  in  possession  of  the  coming  gen- 
eration. Nor  once  more,  if  it  taught  them,  would  it 
provide  the  facilities  needed.  Economic  conditions 
must  change  and  change  specifically  to  aid  the 
mother  if  we  are  to  gain  at  all.  Also,  the  prevention 
of  disease  must  engage  the  serious  attention  of 
governments — the  prevention  of  disease,  not  the 
talking  about  it  or  the  looking  wise  over  it,  or  the 
making  of  fine  addresses  on  it,  but  preventing  it. 
Such  prevention  may  include  a  tremendous  organiza- 
tion to  prevent  human  discharges  entering  water 
supplies,  milk  supplies,  food  supplies;  must  involve 
watchfulness  of  hotels,  restaurants,  public  institu- 
tions of  all  sorts — in  short,  of  all  public  alimentary 
utilities,  wnth  all  their  off-shoots  and  side  issues 
wherever  found.  It  must  include,  as  its  chief  and 
most  efficient  weapon,  the  finding  of  the  sources  of 
infection,  and  the  prevention  of  spread  of  infection 
from  those  sources.  This  is  peculiarly  a  govern- 
mental function,  but  the  whole  must  be  cooperative. 
The  government  must  strike  at  the  sources  and  at 
the  public  routes  of  infection.  The  woman  must 
strike  at  the  private  routes.  The  man  must  support 
both  methods  for  the  sake  of  the  women  and 
children. 


TABLE  OF  CONTENTS 

Page. 

CHAPn.K          I.     THE  OLD  PRINCIPLES  AND  THE  NEW  9 

The    Revolution 9 

The    Old    Teachings 11 

The    New    Ideas 13 

Environment     14 

Chapter        II.     INFECTIOUS     DISEASES 16 

Facts     16 

(a)    Sources,  of  Infectious   Diseases.  .  .  19 

(&)    Routes   of  Infectious  Diseases.  ...  21 

(c)    Control  of  Infectious  Diseases.  ...  22 

Chapter      III.     NON-INFECTIOUS     DISEASES 23 

Speculations     23 

The    General    Problem 25 

The  Present   Situation 27 

Immediate   Possibilities    30 

Education    32 

Medical   Supervision    of   Schools 34 

Summary    36 

CHAPTi:K       IV.     THE  OLD  PRACTICE  AND  THE  NEW  39 

Epidemiology     39 

Comparative    Methods 40 

The  New  Emergency  Epidemiology....  43 

Finding   the   Unknown    Cases 47 

Summary     48 

Chapter         V.     THE    NEWEST    PRACTICE 50 

Concurrent     Epidemiology 50 

Future    Applications 54 

Chief     Infectious     Diseases,     Classified 

by     Routes 57 

The    New    Program 59 

Chapter       VI.     INDIVIDUAL   DEFENSE    63 

Public   Defense  and   Private 63 

The    Preventability    of    "Preventable" 

Diseases    63 

"Dodging     Infection" 66 

"Contact"      67 

Placard  for  Schools   72 

Summary       76 

7 


Chapter     VII.     COMMUNITY   DEFENSE    78 

The    Public    Health    Engineer 78 

Summary    85 

Chapter  VIII.     COMMUNITY    DEFENSE 87 

The    Public    Health    Laboratory 87 

Summary    93 

Chapter       IX.     COMMUNITY      DEFENSE 94 

The  Public  Health   Statistician 94 

Statistics  as  They   Will   Be 95 

Statistics    as    They    Are 98 

Summary      106 

Chapter         X.     COMMUNITY    DEFENSE   APPLIED 108 

Tuberculosis    in    General 108 

Human    Tuberculosis    109 

The     Abolition     of     Cattle     Tubercu- 
losis  from    the   human 112 

The    Abolition     of    Human     Tubercu- 
losis   113 

Summary      119 

Chapter       XI.     THE    CONCLUSION    OF    THE    WHOLE 

MATTER     121 

The    Doing    of    It 121 

The    Chief    Objections 121 

Popular   Fallacies    125 

New  Fashioned  Quarantine 126 

Summary      128 


THE  NEW  PUBLIC  HEALTH 

Chapter  I 
THE  OLD  PRINCIPLES  AND   THE  NEW 

THE  REVOLUTION 

The  statement  that  there  is  a  "New  PubHc 
Health"  may  shock  those  who,  although  familiar 
with  recent  changes  in  scientific  thought,  yet 
have  not  fully  realized  what  those  changes  mean ; 
but  the  shock  will  be  far  greater  to  those  who 
have  not  appreciated  that  changes  were  going  on. 

The  purpose  of  the  writer  is  to  formulate  for 
both  groups,  the  unconscious  progressive  and  the 
unconscious  conservative,  a  brief  statement  of 
the  essential  principles  of  modern  official  public- 
health  work.  To  those  who  may  feel  skeptical  as 
to  the  fairness  of  this  exposition,  the  writings  of 
Chapin,  the  great  American  pioneer  of  modern 
public  health,  of  E.  O.  Jordan,  and  of  M.  N. 
Baker,  may  be  offered  as  bearing  directly  upon 
these  questions,  while  the  whole  of  modern  tech- 
nical public-health  literature  may  be  offered  as 
indirect  evidence. 

The  old  principles  have  merged  gradually  into 
the  new,  in  keeping  with  the  experiments,  ob- 
servations, and  conclusions  of  many  investigators 
in  many  individual  sciences  related  to  general 
public  health.  Within  official  public-health  cir- 
cles, bacteriology,  clinical  observation,  and  mathe- 
matics have  furnished  most  of  the  reconstruction. 
The  bacteriologist,  the  epidemiologist,  and  the 
vital    statistician,    sometimes    working   together, 


more  often  alone,  in  the  dark  and  even  at  cross 
purposes,  have  nevertheless  all  reached  the  same 
point,  and  today  each  finds  his  co-workers  be- 
side him.  Much  of  the  work  done  has  consisted 
in  clearing  away  the  fallacies  built  up  by  tradi- 
tion, but  construction-work  has  gone  on  also,  and 
it  is  now  possible  to  formulate  the  results. 

The  essential  change  is  this:  The  old  public 
health  was  concerned  with  the  environment;  the 
new  is  concerned  with  the  individual.  The  old 
sousrht  the  sources  of  infectious  disease  in  the 
surroundings  of  man ;  the  new  finds  them  in  man 
himself. 

The  old  public  health  sought  these  sources  in 
the  air,  in  the  water,  in  the  earth,  in  the  climate 
and  topography  of  localities,  in  the  temperature 
of  soils  at  four  and  six  feet  deep,  in  the  rise  and 
fall  of  ground-waters ;  it  failed  because  it  sought 
them,  very  painstakingly  and  exhaustively,  it  is 
true,  in  every  place  and  in  every  thing  ivherc 
they  were  not. 

The  new  public  health  seeks  these  sources — 
and  finds  them — amongst  those  infective  persons 
(or  animals)  whose  excreta  enter  the  bodies  of 
other  persons. 

The  old  public  health  failed  to  find  the  sources 
of  infection ;  it  also  failed  in  most  instances  to 
find  the  routes  of  transmission.  It  is  true  that 
public  water-supplies  were  detected  as  at  times 
transmitting  infection ;  but  milk  was  hardly  sus- 
pected twenty  years  ago,  and  flies,  suggested  in 
1887,^  were  not  seriously  considered  until  the 
Spanish-American      war ;       mouth-spray-      and 


^Wm.  H.  Welch:  Address  at  tlie  Annual  Meeting  of  the  Medi- 
cal and  C"hiriiri?ical  Faculty  of  Maryland  18S7,  quoted  in  "Sew- 
age and   Local   Drainage." — Waring,   1889. 

-By  this  is  meant  the  fnie  droplets  thrown  out  from  the  mouth 
in    sjjeaking,    singing,    laughing,    sneezing,   coughing,    etc. 

10 


hands  have  been  only  recently  recognized  as  im- 
portant. On  the  other  hand,  dirty  clothes,  bad 
smells,  damp  cellars,  leaky  plumbing,  dust,  foul 
air,  rank  vegetation,  swamps,  stagnant  pools,  cer- 
tain soils,  smoke,  garbage,  manure,  dead  animals, 
in  fact  everything  physically,  sensorially,  estheti- 
cally,  or  psychically  objectionable,  were  lumped 
together  as  "unsanitary"  without  much  distinc- 
tion of  ''source"  or  ''route,"  and  were  regarded 
as  a  sort  of  general  "cause  of  disease"  to  be  con- 
demned wherever  found,  "for  fear  of  epidem- 
ics." 

THE  OLD  TEACHINGS 

It  was  taught  that  infectious  diseases  "gener- 
ated" in  the  foul,  ill-smelling,  unventilated,  sun- 
less hovels  of  the  slums.  In  the  vogue  of  ^those 
days,  "the  slum-dwellers  live  like  pigs,  and  there- 
by invoke  the  coming  of  smallpox,  scarlet  fever, 
t3'phoid  fever,  diphtheria."  When  these  diseases 
iuAaded  the  home  of  the  well-to-do,  where  this 
explanation  was  not  seemly,  a  pinhole  leak  in 
some  plumbing  fixture  accounted  amply  for  diph- 
theria :  rotten  potatoes,  forgotten  in  a  dark  corner 
of  the  cellar,  for  typhoid  fever ;  scarlet  fever  was 
traced  to  a  letter  from  a  friend  who  had  had  the 
disease  months  before ;  smallpox  to  unpacking 
books  used  by  a  patient  a  cjuarter  of  a  century 
previously ;  manure  piles  gave  rise  to  cholera ; 
and  dampness  to  malaria,  which  was  not  recog- 
nized as  transmissible  at  all.  Yellow  fever  orig- 
inated in  impure  water  and  was  directly  transmit- 
ted from  person  to  person — a  typical  example  of 
intense  direct  contagion ;  tuberculosis  was  non- 
infectious and  hereditary ;  bubonic  plague  v/as 
banished  from  the  Egyptian  Cairo  "simply  by 
improving  the  ventilation  of  the  city"  (  !)^ 

iParke's  Hygiene,  1891;  eighth  edition.  This  was  a  standard 
work   of   twenty   years  ago. 

11 


Remedial  and  preventive  measures,  based  on 
such  beliefs  in  the  omnipotence  of  environment, 
naturally  sought  to  remodel  the  lives  and  im- 
mediate home  surroundings  of  the  whole  popu- 
lation to  conform  with  a  vast  array  of  alleged 
"sanitary  laws  of  health."  Yet  he  who  seeks  for 
a  scientific  demonstration  of  the  relations  existing 
between  disobedience  of  these  "sanitary  laws" 
on  the  one  hand,  and  the  incidence  of  disease  and 
death  on  the  other,  will  find  only  a  "twilight 
zone"  in  which  move  vague  shadows  of  tradition- 
al fear,  shadows  which,  on  probing,  fade  mistily 
away.^ 

The  Xew  Public  Health  is  not  worried  by 
elaborate  theoretical  possibilities,  but  concerns 
itself  earnestly  with  practical  probabilities.  The 
occasional,  unusual,  bizarre  routes  of  infection 
in  the  one  per  cent  of  cases,  do  not  distract  its 
attention  from  the  usual,  practically  constant, 
simple,  ordinary  routes  concerned  in  the  ninety- 
nine  per  cent.  Its  main  postulate  is  that  the 
routes  of  infection  are  simply  the  routes  of  in- 
fected bodily  discharges,  which,  again,  are  iden- 
tical with  the  routes  of  ordinary  uninfected  dis- 
charges in  ordinary  life. 

The  old  style  "sanitary  inspector"  was  expect- 
ed to.  and  usually  did,  "condemn"  everything  in 
sight,  from  the  garbage  pail  at  the  back  door  to 
the  plumbing  in  the  bath-room.  But  disease 
continued,  because  he  was  condemning,  as  a  rule. 
so  far  as  health  was  concerned,  things  largely 
"incomi>etent.  irrevelant  and  immaterial."  What 
availed  it  that  the  garbage-pail  was  emptied  ever}' 
day  or  a  vent-pipe  placed  on  the  bath-water 
waste-trap,  if  the  milkman  delivered  scarlet- 
fever-infected  milk  at  the  door,  or  an  imrecog- 


'Soe  Journal-Lancet   of  July    15.   1914. 

12 


nized  case  of  measles   sat  next  the   children  at 
school  ? 

THE    NEW    IDEAS 

The  New  Public  Health  sees  in  the  garbage- 
pail  merely  a  place  where  flies  are  fed  and,  pos- 
sibly, bred.  But  the  flies  cannot  carry  infection 
if  infected  discharges  are  not  accessible  to  them. 
"Defective  plumbing,"  such  a  nightmare  twenty 
years  ago,  has  been  conclusively  shown  to  have 
nothing  to  do  with  disease-generation  or  disease- 
propagation  whatever,  unless  perchance  there  be 
actual  gross  leakage  of  infected  sewage.  The 
unventilated  front  parlor  could  not  produce  tuber- 
culosis in  a  hundred  years ;  diphtheria  does  not 
develop  from  the  family  well ;  and  typhoid  fever 
in  sand  or  clay  soils  is  but  seldom  properly  trace- 
able to  that  source,  either.  The  modern  public 
health  man  cares  nothing,  so  far  as  restriction  of 
disease  and  death  is  concerned,  for  the  dirty  back 
yard  or  the  damp  cellar  in  themselves,  but  only 
as  they  may  enter  into  the  transmission  of  in- 
fected discharges.  Then,  at  once,  they  become  of 
vital  importance.  The  sanitary  inspection  of  the 
modern  sanitarian,  so  far  as  relates  to  infection, 
begins  and  usually  ends  with  the  search  for  (a) 
the  infected  individual;  (b)  the  routes  of  spread 
of  infection  from  that  individual;  (c)  the  routes 
of  spread  of  the  ordinary  excreta  of  ordinary  un- 
infected individuals  to  the  mouths  of  their  ordi- 
nary associates  in  ordinary  life.  These  latter  are 
sought  for,  not  because  of  danger  from  such 
uninfected  discharges,  but  rather  because  in- 
fected discharges,  introduced  into  and  follow- 
ing the  same  well-beaten  paths,  will  necessarily 
reach  the  same  mouths.  To  locate  all  the  infec- 
tive persons  and  to  guard  all  their  discharges 
would  be  wholly  sufficient,  but  since  this  cannot 

13 


always  be  done  perfectly,  it  is  well  to  guard  also 
the  routes  which  unlocated  infection  may  take. 

EXVIROXMEXT 

Has  environment,  then,  nothing  to  do  with  in- 
fectious diseases?  Environment  acts  in  two  ways  : 
First,  unequivocally  and  without  reserve,  such 
environments  as  permit  or  encourage  or,  still 
worse,  necessitate  the  exchange  of  human  excreta 
in  ordinary  life,  contribute  in  the  long  run  to 
the  spread  of  disease  since  they  insure  a  similar 
exchange  of  infected  excreta  so  soon  as  the  lat- 
ter are  introduced.^  Let  us  take  one  environ- 
mental evil,  overcrowding,  as  an  example.  Over- 
crowding, if  combined  with  lack  of  discipline  and 
order,  and  lack  of  facilities  for  washing,  espe- 
cially for  the  washing  of  hands,  contributes  to 
the  spread  of  infectious  diseases;  but  not  in  itself, 
nor  at  all,  unless  infection  be  introduced  into  the 
community.  Then  overcrowding,  because  it 
tends  to  insure  exchange  of  human  excreta,  tends 
also  to  insure  that  the  infection  will  spread  rap- 
idly and  extensively.  But  overcrow^ding,  if  the 
overcrowded  be  disciplined,  intelligent,  and  take 
proper  precautions  to  avoid  exchange  of  excreta, 
does  not  necessitate  the  spread  of  infection,  even 
if  it  be  introduced.  On  the  other  hand,  infec- 
tion may  spread,  and  frequently  does,  without 
overcrowding,  if  the  essential  factor  of  such 
spread  exist,  i.  e..  the  transmission  of  infected 
excreta. 

Second.  Environments  that  are  bad  from  a 
physiological  standpoint  (bad  for  the  body,  re- 
garded as  a  delicate  biological  machine)  are  often 
held  to  act  in  spreading  infection  indirectly  by 


lAn  excellent  exposition  of  this  effect  of  environment  on  the 
spread  of  disease  is  given  by  Chapin  in  the  Report  of  the  Provi- 
dence   Health    Department    for    1910. 

14 


"depressing"  vitality"  to  an  extent  which  makes 
infection,  if  received,  more  likely  to  develop  (and 
if  it  develop,  more  successful  in  injuring  the 
body).  It  must  be  said,  however,  that  the  evi- 
dence on  this  point,  except  perhaps  that  relating 
to  tuberculosis  and  pneumonia,  is  very  slight.  It 
is  a  debatable  question  whether  or  not  over- 
crowding "depresses  vitality"  in  the  direction  of 
increasing  susceptibility  to  infectious  diseases, 
whatever  its  effect  may  be  in  encouraging  '^gen- 
eral  debility."  It  is  a  very  debatable  question 
whether  or  not  ''poor  ventilation,"  to  which  the 
eft'ects  of  overcrowding  are  often  attributed,  can 
or  does  "depress  vitality"  in  the  direction  of 
lessening  resistance  to  infectious  diseases,  what- 
ever bad  effects  it  may  have  on  mental  vigor  or 
physical  activity.  It  is  true  that  there  is  evidence 
that  such  environments  as  lead  to  extremes 
(beyond  the  limits  of  compensatory  adjustments 
by  the  body  forces)  of  mal-nutrition,  of  tempera- 
ature,  of  fatigue,  and  of  alchoholism,  probably 
may  have  an  effect  in  insuring  the  development 
of  infection,  which  under  better  conditions  might 
be  negatived  by  the  body  forces.  Especially  may 
these  forms  of  bad  physiological  environment  be 
influential  when  the  dose  of  infection  is  small, 
infrequent,  or  low  in  virulence.  But  starvation, 
unsuitable  temperature,  fatigue,  alchoholism, 
alone  or  together,  cannot  induce  infection,  nor 
will  the  converse  conditions,  alone  or  together, 
offset  the  effects  of  infection  when  the  dose  is 
large  or  frequently  repeated  or  of  high  virulence. 


15 


Chapter  II 
INFECTIOUS  DISEASES 

FACTS 

It  would  appear,  then,  that  environments  af- 
fecting bodily  functions  have  little  to  do  directly 
with  the  incidence  of  most  of  the  specific  infec- 
tions/ notwithstanding  that  nutrition,  tempera- 
ture, fatigue,  and  alcoholism  are  generally  cred- 
ited with  some  effect,  especially  in  pneumonia  and 
tuberculosis. 

Damp,  cold,  and  fatigue  perhaps  precipitate  the 
pneumonias,  provided  one  of  the  infective  agents 
be  present.  The  environments  that  precipitate 
tuberculosis  constitute  a  problem  as  yet  unsolved. 
Very  much  is  widely  believed,  and  even  more  is 
freely  taught,  concerning  this  subject,  but  the 
evidence  is  tangled  and  often  contradictory. 
"Poor  ventilation,"  dust,  dampness,  etc.,  have  all 
been  accused,  but  very  little  has  been  proved  con- 
cerning the  real  factors  actually  at  work  or  their 
mode  of  operation.  In  the  other  infectious  dis- 
eases the  effects  even  of  extremes  of  the  above 
factors  are  but  rarely  definitely  recognizable. 
One  thing,  and  one  thing  only,  is  absolutely  es- 
tablished, namely,  that  tuberculosis,  microbic 
pneumonia,  and  the  other  infectious  diseases  will 
develop  under  almost  any  circumstances  if  the 

iThe  terms  contagious  and  infectious  were  formerly  carefully 
used  and  carefully  distinguished.  Modern  writers,  however, 
fail  to  find  any  useful  or  basic  significance  in  "contagious"  as 
contrasted^  with  "infectious."  Hektoen,  in  Osier's  "Modern 
Medicine,"   discards  "contagious"  and   "contagion"  entirely. 

In  these  articles  "infectious"  is  used  to  mean  "transmissible" 
or   "communicable." 

16 


monia,  and  the  other  infectious  diseases  will  devel- 
op under  almost  any  circumstances  if  the  dose 
of  infection  be  large  enough,  virulent  enough,  or 
sufficiently  repeated.  Tuberculosis,  pneumonia, 
and  the  other  infectious  diseases  will  not  develop 
under  any  circumstances  without  such  infection. 

Hence  it  must  be  evident  that  the  sine  qua  non 
of  all  infectious  diseases  are  their  respective 
agents,  and  that,  since  the  chief  sources  (infec- 
tive persons)  of  these  are  known,  the  most  logi- 
cal efforts  are  those  w^hich  concentrate  on  the  pre- 
vention of  the  dissemination  of  these  agents  from 
these  sources. 

This  is  tenable,  not  only  in  theory,  but  in  prac- 
tice, and  presents  an  infinitely  simpler  adminis- 
trative problem  than  that  presented  by  the  older 
hypotheses, — not  only  in  the  minor  infectious  dis- 
eases, where  these  principles  have  been  practically 
accepted  by  all,  but  even  in  tuberculosis  itself. 

Thus,  if  "general  environment"  be  the  great 
factor  in  tuberculosis,  the  two  million  people  of 
Minnesota  must  have  each  his  or  her  own  indi- 
vidual environment  brought  up  to  and  kept  at 
some  standard-level  designed  to  maintain  each 
individual  in  his  or  her  own  alleged  ''highest 
state  of  health." 

If,  however,  the  infectiveness  of  the  disease  be 
the  great  factor,  only  three  thousand  people  (the 
actively  infective  cases)  need  this  supervision, 
in  Minnesota,  and  they  need  it,  not  for  the  im- 
provement of  their  "general  environment,"  but 
merely  to  prevent  them  from  infecting  others. 
This  problem,  even  numerically,  is  but  one  seven- 
hundredth  the  magnitude  of  the  other.  Consider 
the  utterly  impracticable  expense  and  difficulty  of 
the  State  attempting  to  insure  only  the  four  quoted 
factors, — good   food,  proper  temperatures,  tem- 

17 


perance,  and  repose, — to  two  million  people  (to 
say  nothino^  of  the  other  "factors  of  safety"  called 
for  by  those  who  lay  chief  emphasis  on  control 
of  environment,  i.  e.,  abolition  of  foul  air,  smoke, 
dust,  damp  cellars,  bad  smells,  dirty  back  yards, 
etc.),  and  contrast  with  this  the  expense  "of  State 
supervision  of  three  thousand  people  merely  to 
the  extent  of  confining  their  infective  discharges 
to  themselves. 

Further  consider  that  the  same  official  mechan- 
ism which  could  control  the  three  thousand  tuber- 
culous could  also  handle  with  but  slight  expan- 
sion the  infectious  persons  needing  supervision 
for  the  prevention  of  all  the  other  infectious  dis- 
eases, except  the  venereal,  as  well  as  the  infec- 
tive tuberculous.  Remember  also  that  improve- 
ment of  the  "general  environment,"  allowing  that 
its  effective  achievement  were  conceivable,  could 
not  be  expected  to  have  any  noteworthy  effect 
on  most  of  these  other  infectious  diseases,  even 
though  it  had  some  on  tuberculosis. 

Need  any  more  be  said  to  indicate  the  supe- 
riority of  the  new  principles  as  practical  business 
propositions,  over  the  old  ?  The  latter  would  re- 
quire the  realization  of  the  millenium  and  an  ex- 
penditure of  untold  millions ;  the  former  could 
be  put  into  operation  in  three  months,  with  an 
expenditure  of  twenty-five  cents  per  head  of  the 
population. 

The  stumbling-block  is  that  the  general  public 
still  believes  the  teachings  of  twenty  years  ago 
concerning  environment.  These  teachings  were 
a  mixture  of  the  "old-wives  fables''  of  the  pre- 
bacterial  age,  with  the  early  incongruities  and 
half-truths  of  the  new  "theory"  of  bacteriology. 

Bacteriology  is  now  an  old-established  science ; 
but  despite  the  fact  that  it  has  changed  public- 

IS 


health  work  even  more  than  it  has  changed  medi- 
cine or  surgery, — and  both  of  these  it  has  com- 
pletely revolutionized, — the  public  still  clings  to 
the  belief  that  public  health  is  _a  curious  profes- 
sion, absorbedly  interested  in  cutting  weeds  in 
vacant  lots  (''to  prevent  epidemics"),  in  burying 
dead  animals  and  suppressing  noisome  odors  ("to 
prevent  epidemics")  ;  in  inspecting  plumbing  and 
collecting  garbage  ("to  prevent  epidemics"). 
(The  "good"  health-officer  is  he  who  keeps  the 
streets  clean  and  the  back  alleys  neat,  and  who 
falls  into  a  rapture  over  a  newly  whitewashed 
outhouse  and  into  a  rampage  if  a  pile  of  old 
bones  is  found  under  the  cellar  steps.  Yet  those 
who  know  better  let  these  ideas  alone,  or  even 
acquiesce  in  them,  "to  save  trouble."  Then  it 
is  expected  that  the  carefully  uneducated,  or 
miseducated,  public  opinion  will  demand  up-to- 
date  laws !  Is  it  any  wonder  that  the  public  in- 
sists on  thinking,  acting,  and  legislating  to  suit 
the  theories  of  twenty  years  ago.  instead  of  the 
scient^fc  knowledge  of  today? 

Creeds   are   often   misleading,   incomplete,   or 
fallacious ;  yet  the  temptation  to   formulate  the 
new  principles  briefly  is  strong,  because  their  in- 
telligent  presentation   to  the   public  is   so  vital.^ 
Such  formulation  is  attempted  here. 

a.  Sources  of  Infectious  Diseases 

1.  Infectious  diseases  are  infectious  because 
they  are  due  to  the  growth,  in  the  body,  of  min- 
ute animal  or  vegetable  forms  (germs),  the  trans- 
missibility  of  these  germs  from  body  to  body  be- 
ing the  sole  explanation  why  these  diseases  are 
"catching." 

2.  Wherever  in  the  body  the  germs  develop, 
they    leave   it   chiefly   in   the   discharges,   or   by 

19 


routes  of  the  discharges,  of  the  nose  and  throat, 
bladder,  or  bowel,  i.  e.,  from  the  main  orifices  of 
the  body.* 

3.  The  discharges  infect  another  person  prac- 
tically only  when  that  person  takes  the  discharges, 
in  some  form,  into  the  mouth  or  nose,  except  in 
trachoma  and  the  venereal  diseases.** 

4.  Outside  the  body, disease  germs  do  not  mul- 
tiply in  nature,  except  perhaps  rarely,  and  very 
temporarily  in  milk,  water,  or  similar  fluids.  In 
general,  even  typhoid  bacilli  disappear  from  water 
supplies  within  two  weeks,  without  evident  mul- 
tipHcation.  If  introduced  into  milk,  most  infec- 
tious-disease germs  die  out  as  the  milk  becomes 
acid,  generally  in  a  day  or  two.  Infectious-dis- 
ease germs  are  rarely  found  in  garbage,  and  they 
quickly  die'  out  if  deliberately  added.  Practical 
modern  public  health  recognizes  therefore  that  the 
bulk  of  most  of  the  infectious  diseases  are  derr/ed 
directly,  or  almost  directly,  from  infected  persons, 
not  much  from  infected  thing^f^xcept  water, 
milk,  food,  and  fliesf  The'T^nger  from  the  gen- 
eral environment  of  an  infected  person  is  there- 
fore smallT '  The  things  in  his  neighborhood  need 
little  consideration,  except  those  very  immediately 
about  him  and  directly  infected  by  his  discharges, 
such  as  bedclothes,  personal  clothes,  towels,  eat- 
ing utensils,  and  other  material  objects  that  may 
receive,  and  retain  for  a  time,  fresh  moist  dis- 
charges.    If  attention  be  efficiently  directed  to  in- 

*This  applies  to  all  the  ordinary  infections  dis- 
eases in  this  state.  Smallpox,  leprosy,  syphilis,  and 
some  forms  of  tuberculosis  are  transferable  from  skin 
lesions  at  times.  Certain  tropical  diseases  are  trans- 
mitted by  insects  tapping?  the  blood-stream,  etc.  Prob- 
ably all  infections  can  be  conveyed,  as  anthrax  and 
tetanus  usually  are,  directly  by  inoculation.  But  these 
paths  are  so  rare  as  to  be  negligible  in  ordinary  life 
here.  , 

**"Infection  is  transmitted  from  an  orifice  of  the  in- 
jector to  an  orifice  of  the  infectee." 

20 


fected  persons  and  their  discharges,  the  general 
surroundings  may  be  safely  ignored,  except  in 
the  rarest  instances. 

b.   Routes  of  Infectious  Diseases 

5.  The  routes  by  which  the  discharges  of  the 
sick  person  pass  to  the  well  person  are  exactly 
those  by  which  the  same  discharges  pass,  from  the 
well  person  to  the  well  person  in  ordinary  life ; 
for  nose  and  mouth  discharges  the  routes  are 
sputum  and  mouth-spray,  cofiveyed  tlirougli  di- 
rect contact  (as  in  kissing,  etc.),  and  by  the 
hands ;  for  bowel  and  bladder  discharges,  the 
hands  chiefly ;  and  for  all  discharges,  the  things 
infected  by  them  directly  or  through  the  hands, 
especially  those  things  which  then  go  to  the 
mouth  or  touch  things  which  go  to  the  mouth, 
as  food,  water,,  eating  utensils,  towels,  pipes, 
etc.,  etc.  Flies  also  furnish  an  effective  route, 
especially  to  food.  Water  supplies  are  peculiar, 
because  bowel  and  bladder  discharges  en  masse, 
in  the  form  of  sewage,  often  enter  thpm  directly, 
at  times  being  deliberately  poured  into  tltem  from 
city  sewers. 

6.  The  relative  importance  of  these  various 
routes  in  the  carriage  of  inf,ection  varies  much. 
The  amount  and  freshness  of  the  discharges,  the 
number  and  virulence  of  the  germs  they  contain, 
the  size  and  frequency  of  the  dose,  and  the  num- 
ber of  susceptible  persons  who  *are  dosed,  must 
always-  be  considered.  Almost  all  the  ordinary 
infectious  disease  germs  die  out  quickly  on  ex- 
posure to  direct  sunlight,  and  fairly  rapidly  ir, 
diffuse  sunlight.  .When  mucus,  feces,  and  urine 
are  thoroughly  dried  on  furniture,  d6or-knobs, 
etc.,  thev  are  not  readily  removed  again  without 
moisture  and  friction,-and  when  so  removed  the 

2-1  . 


disease  germs  in  them  are  likely  to  be  dead  or 
greatly  reduced  in  recuperative  power  because 
of  the  drying.  Hence,  as  a  rule,  tilings  succeed 
in  conveying  infection  only  somewhat  directly 
from  the  infector  to  the  infectee,  and  practical!}' 
only  during  the  limited  period  when  the  germs 
are  still  fresh  and  moist. 

c.    Control  of  Infectious  Diseases 

7.  These  new  principles  place  at  the  head  #f 
official  public  health  activities,  the  search  for  and 
supervision  of  infected  persons,  and  the  control 
of  the  infected  discharges,  for  the  purpose  of 
excluding  them  from  mouths,  and  therefore  also 
from  food  and  drink.  Prompt  intelligent  (jjsui- 
fection  of  all  the  excreta  immediately  after  their 
discharge  from  the  body,  is  the  best  weapon  in 
the  supervision  of  infected  persons.  Isolation 
of  the  infected  person  is  the  next  best,  and  is 
more  universally  practicable,  because  immediate 
intelligent  disinfection  of  discharges  can  rarely 
be  secured  outside  of  the  very  best  hospitals  for 
contagious  disease.  The  search  for  and  super- 
vision of  mild,  early,  convalescing,  unrecognized, 
and  concealed  cases  and  carriers,  as  well  as  of 
frank  cases,  is  necessarily  an  essential  item  in 
the  scheme. 

8.  The  modern  public-health  department  re- 
quires experts,  but  not  experts  m  municipal  house- 
keeping, in  street-cleaning,  garbage-disposal, 
smoke-prevention,  etc.  Its  experts  are  the  vital 
statistician,  the  epidemiologist,  the  laboratory 
man,  and  the  sanitary  engineer,  the  latter  dealing 
chiefly  with  the  broad  questions  of  water-supply 
and   sewage-disposal. 


i 


Chapter  III 
NON-INFECTIOUS  DISEA'SES 

SPECULATIONS 

The  previous  chapters  indicated  that  so  far  as 
the  infectious  diseases  are  concerned,  the  great 
pubHc-health  fallacy  of  the  19th  century  con- 
sisted in  the  devotion  of  nearly  all  the  effort  to 
man's  surroundings ;  of  almost  none  at  all  to  man 
himself.  We  know  now  that  the  sources  of  in- 
fection are  in  man ;  that  the  routes  of  infec- 
tion are  the  routes  of  man's  discharges ;  and 
•that  the  discharges  are  harmless  until  they  enter 
man  again.  It  is  true  that  when  the  infective 
agents  reach  their  goal  the  resistance  of  the  indi- 
vidual, pitted  against  the  injurious  powers  of  the 
in»tive  agents,  decides  whether  or  not  actual 
disease  develops^  But  this  resistance  of  the  indi- 
vidual i#not  to  be  measured  by  his  surroundings  : 
it  is  intrinsic  in  himself.  Alterations  of  intrinsic 
resistance  do,  of  course,  constantly  occur,  but 
%  the  factors  of  those  alterations  are  not,  as  a  rule, 
ft  to  be  readily  ascertained.  We  think  that  great 
extremes  of  malnutrition,  temperature,  and  so 
forth  may  ''depress"  resistance.  We  have  evi- 
dence that  the  smoke  nuisance,  poor  ventilation, 
'  or  smells  from  slaughter-houses  do  not.  In 
brief,  granted  sufficient  exposure  to  infectious 
disease,  the  susceptible  individual  will  succumb, 
though  he  live  in  a  palace ;  the  immune  individ- 
ual will  escape,  though  he  dwell  in  the  slums.* 

♦Tuberculosis  has  long  been  held  an  exception  to 
this  rule.  But  tuberculosis  was  also  long  held  as  (a) 
non-infectious  and  (b)  hereditary,  as  weU  as  (c)  a  re- 
sult of  certain  surroundings.  We  have  reversed  (a) ; 
we  have  reversed  (b);  we^may  yet  see  good  reasons 
to  modify    (c).  j 

23 


The  outcome  of  the  19th  century  environ- 
mental doctrines  was  the  binding-  of  heavy  bur- 
dens of  routine  administration  concerning  sur- 
roundings upon  heaUh  departments.  Results : 
garbage  disposal,  a  polytechnic  trade ;  street- 
cleaning,  a  scientific  profession ;  plumbing,  a  fine 
art ;  and  the  supervision  of  infection,  a  dubious 
and  usually  a  temporary  ''job."  ^^ 

We  have  pursued  chimeras ;  pursued  them  in 
good  faith  of  course,  but*chimeras  none  the  less. 

Suppose  now  that  we  admit  our  errors  and 
give  to  the  supervision  of  tuberculosis,*"^'  which 
we  do  understand,  one-half  the  effort  we  have 
given  to  the  supervision  of  ventilation,  which 
we  do  not  understand.  Suppose,  in  brief,  we 
really  organize  and  really  operate  a  real  ma- 
chine which  really  does  reduce,  even  promises  to 
abolish,  the  infectious  diseases.  Will  it  be  a  sur- 
render of  our  birthrights  for  a  mess  of  pottage 
if  we  forego  the  chasing  down  of  loose  paper 
on  the  streets  and  the  cleaning  up  of  rubbish  piles 
on  vacant  lots,  to  turn  our  attention  solely  to 
the  ''mere  abolition  of  infection''?  Are  there  not 
activities  contributing  to  health  beyond  these 
limits  ?  Surely,  yes ;  and  some  of  them  are 
things  that  should  be  done  at  once  without  wait- 
ing for  that  "mere  abolition"  to  be  accomplished. 
For  example,  everyone  knows  that  the  bodily 
welfare  of  mankind  does  not  by  any  means  hinge 
wholly  on  the  infectious  diseases.  True,  the 
abolition  of  these  diseases  means  also  the  aboli- 
tion of  their  immediate  sequelae, — sometimes 
as  in  measles,  more  harmful  than  the  original 
attack, — and  of  their  remote  sequelae,  the  per- 
manently injured  kidney  and  the  permanently 
weakened  lung.     But  even  so,  a  full  half  of  our 

**To  say  nothing  of  syphilis,  gonorrhea,  summer 
diarrhea,  and  the  rest. 

24 


medical  diseases  and  much  more  than  half  of 
our  surgical  diseases  would  still  remain ;  more- 
over, merely  to  remove  disease  is  not  to  solve  the 
whole  problem  of  securing  health  in  its  true 
sense,  i.  e.,  the  highest  physical  efficiency  pro- 
longed for  the  greatest  period  of  time. 

THE  GENERAL  PROBLEM 

The  chief  of  the  many  phases  of  disease  and 
health   are   best   shown   by   a  parable : 

As  a  new  automobile  is  accompanied  by  de- 
tailed instructions  for  its  care  and  operation,  so 
the  new  small  citizen  should  be  accompanied  by 
detailed  instructions  for  his  care  and  operation 
when  he,  a  delicate  and  complicated  machine, 
indeed,  first  appears  on  the  scene.  This  knowl- 
edge is  now  accumulated  by  his  parents  chiefly 
from  experience  (which,  remember,  are  his  ex- 
periences) or  by  picking  it  up  at  random  from 
the  neighbors  over  the  back-yard  fence. 

Again :  As  a  new  automobile  is  searched  so- 
licitously for  missing  or  defective  parts,  to  be 
solicitously  and  'immediately  made  good  before 
the  machine  is  sent  out  to  run  against  competi- 
tors on  the  highway,  so  the  new  small  citizen 
should  have  at  least  his  sight,  his  hearing,  and 
his  breathing  tested  before  he  begins  the  in- 
evitable compulsory-education  race  against  all 
comers  on  the  public  highway  of  the  public 
schools.  But  further :  As  the  most  initially  per- 
fect automobile,  most  skillfully  run,  will  yet,  as 
time  goes  on,  meet  accidents,  develop  internal 
disruptions,  and  require* repairs,  so  the  new  small 
citizen,  despite  early  care  and  early  correction 
of  defects,  will  need  supervision  and  repair  all 
through  his  life,  at  school  and  afterwards. 

The   parable  must  end  here,   for  automobiles 

25 


present  no  affections  analogous  to  infectious  dis- 
eases. This  very  fact,  however,  brings  out  more 
clearly  the  crucial  distinction  between  man  as  a 
machine  and  man  as  a  subject  of  infection.  As 
a  machine,  he  may  be  efficient  or  inefficient,  well 
operated  or  ill  operated,  and  this  all  quite  apart 
from  the  existence  of  actual  defect  or  disability. 
Contrariwise,  as  a  machine  he  may  suffer  initial 
defects  or  encounter  accidents  or  develop  internal 
disruptions,  all  quite  apart  from  his  intrinsic 
^  efficiency  or  inefficiency  and  quite  apart  from  the 
skill  with  which  he  is  operated.  But  as  a  subject 
of  infection,  man  is  merely  a  soil  more  or  less 
well  suited  to  the  growth  of  certain  small  plants, 
or  animals.* 

The  most  valuable  production  of  the  state  is 
its  citizens,  and  the  state  exists  only  to  insure 
life,  liberty,  and  the  pursuit  of  happiness  to  them. 
As  the  automobile  maker  insists,  for  his  ozvn  sake, 
on  (a)  giving  instructions  and  (b)  correcting 
defects;  so  the  state  should,  for  its  own  sake,  (a) 
instruct  parents  and  (b)  remedy  children's  de- 
fects, perhaps  also  the  defects,  disabilities,  and 
diseases  of  adults.  Certainly,  every  state  should 
provide  at  least — 

/teducation  for  parents  in  the  personal  hygiene 
or"  children,  i.  e.,  the  care  and  operation  of 
their  children's  bodies  as  machines ;  and  educa- 


*The  fact  that  in  their  growth  these  little  invaders 
from  without  "mess  up  the  works"  and  make  trouble, 
as  much  as  would  disruptions  originating  wholly 
from  within,  should  not  conceal  the  radical  difference 
between  the  sources  and  causes  of  defects,  disabilities, 
and  non-infectious  diseases  on  the  one  liand,  and  of 
the  infectious  diseases  on  the  other.  The  former  may 
develop  in  any  mechanism;  the  latter  only  in  those 
mechanisms  which  furnish  a  suitable  soil  for  the 
growth  of  the  extraneous  invaders.  To  prevent  the 
former  the  machine  must  be  well  built  and  of  the 
best  stock,  must  be  scrupulously  watched  for  defects, 
must  be  constantly  overhauled,  and  must  be  cared  for 
and  operated  in  the  most  skillful  manner.  To  prevent 
the  latter  the  mere  exclusion  of  the  invaders  is  all- 
sufficient. 

26 


tion  also  for  children  in  the  physical  care  of 
themselves. 

Supervision,  not  only  for  the  mere  detection, 
but  also  for  the  remedy,  of  initial  defects, 
and  should  provide  this  early  in  life,  certainly  not 
later  than  the  beginning  of  the  compulsory-edu- 
cation course. 

Supervision  of  children  at  least  throughout 
school-life  for  the  detection,  and  remedy,  of  such 
defects,  disabilities,  or  diseases  as  may  develop 
during  that  period. '='  . 

The  supervision  of  infectious  diseases.  X  ^ 

THE    PRESENT    SITUATION 

But  of  all  the  manifold  duties  of  the  state  to 
the  citizen,  only  one  of  those  which  can  be  clearly 
shown  to  bear  directly  on  his  bodily  welfare,  has 
beer^as  yet  really  recognized  fully  here — only  one 
rests  on  definite  precedent  authorization  and  or- 
ganization, the  supervision  of  infectious  diseases. 
The  personal  hygiene  of  the  citizen  (apart  from 
the  infectious  diseases),  and  the  remedy  (even, 
until  lately,  the  mere  detection)  of  his  defects, 
disabilities,  or  non-infectious  diseases,  have  been 
regarded  (except  in  the  case  of  the  pauper,  the 
criminal,  or  the  insane)  as  of  little  or  no  interest 
to  anyone  but  himself.  And  this,  notwithstand- 
ing that  all  his  material  surroundings,  and  all 
his  relationships,  business  and  social,  have  been 
of  acknowledged  interest  to  the  state  from  time 
immemorial. 

Why  this  apparent  negligence?  First,  because 
material  surroundings  are  property,  and  prop- 
erty has  always,  had  precedence  over  persons  in 
almost   every   relation ;    second,   because,    in   the 

*It  is  difficult  to  see  strictly  logical  reasons  why 
such  supervision  should  end  with  school-life.  Ger- 
many and  England  are  experimenting  with  the  medi- 
cal supervision  of  adults. 

27 


special  relation  to  disease,  the  old  public  health 
taught  that  the  citizen  was  a  result  of  his  sur- 
roundings, and  even  in  the  infectious  diseases 
this  fallacy  ruled,  as  has  been  abundantly  shown. 
^  Of  course,  ^le  state  is  concerned  with  man's 
surroundings  and  relationships.  It  must  consider, 
plan  for,  and  carry  out  measures  for  his  com- 
fort, convenience,  safety,  pleasure,  and  happi- 
ness, as  well  as  merely  for  his  health.  The  state 
exists  to  do  for  its  citizens  co-operatively,  hence 
economically  and  authoritatively,  all  those  neces- 
sary things  which  the  individual  could  do  only 
by  great  sacrifices  or  perhaps  not  at  all.  But  to 
believe  that  the  securing  to  the  individual  of 
every  possible  advantage  in  all  directions  is  the 
duty  of  the  state,  is  not  necessarily  to  believe 
that  every  item  of  this  program  should  be  car- 
ried out  by  health  departments.  To  hand  over  to 
any  one  subdivision  of  the  government  control 
both  of  man  and  of  his  surroundings,  would  be 
to  hand  over  to  it  all  the  functions  of  govern- 
ment. At  once,  subdivision  of  these  activities 
would  be  necessary  and  these  subdivisions  would 
necessarily  pattern  after  those  of  the  present 
government.  Hence  such  a  ''readjustment"  would 
merely  replace  existing  governments,  not  add  to 
their  existing  efficiency. 

The  secret  of  successful  organization  is  the 
parcelling  out  along  natural  lines  of  all  the  dif- 
ferent activities  which  are  to  be  co-ordinated  to 
one  great  end.  It  is  upon  the  shrewdness  with 
which  the  subdivision  into  logical  natural  groups 
is  done  that  the  securing  of  smoothly-running 
co-ordination  depends.  Certainly,  one  most  logi- 
cal grand  division  of  any  government  would  be 
that  which  should  deal  with  man  apart  from  his 
surroundings ;  and  one  most  logical  subdivision 

28 


of  that  unit  should  deal  with  his  bodily  welfare 
as  distinct  from  his  mental,  moral,  or  other  wel- 
fare. 

Using  the  automobile  parable  for  guidance, 
such  a  "Commission  on  Bodily  Welfare"  should 
deal  with — 

Item  1.  The  education  of  ^z/^rj;  ci/i^^w  in  per- 
sonal hygiene. 

Item  2.  The  supervision  of  every  citizen  for 
detection  of  defects,  disabilities,  and  disease. 

Item  3.  The  treatment  of  every  citizen  for  all 
defects,  disabilities,  and  diseases  detected. 

Item  4.  Finally,  that  function  to  which  the 
automobile  analogy  does  not  apply,  i.  e.,  the  sli- 
pervision  of  that  small  group  of  citizens,  the  in- 
fectious persons. 

How  closely  do  we  in  Minnesota  approximate 
this  ideal? 

Proper  education  of  every  citizen  in  personal 
hygiene  {apart  from  the  infectious  diseases)  is 
scarcely  even  foreshadowed  by  existing  efforts. 

Medical  supervision  (apart  from  the  pauper, 
the  criminal,  and  the  insane)  is  limited  to  a 
small  portion  only,  of  the  school  children  only, 
in  a  few  cities  only;  and  does  not  pretend  to 
remedy  defects,  but  only  to  detect  them.* 

Treatment  of  disease  (except  for  the  pauper^ 
the  criminal,  and  the  insane)  is  a  matter  of  pri- 
vate purchase  or  of  private  philanthropy,  usuall}^ 
the  private  philanthropy  of  the  private  practicing 
physician. 

The  supervision  of  infectious  persons  is  alone% 
really  established,  authorized,  or  organized  as  ^ 
a  recognized  duty  of  the  state  throughout  the" 

♦About  two-thirds  of  the  children  of  tlie  state  live 
and  attend  school  in  rural  districts  where  medical 
supervision  for  defects  is  hardly  yet  even  contem- 
plated, 

29 


state,  and  then  only  so  far  as  the  protection 
of  others  is  concerned.  Wt  have  not  yet  reached 
the  treatment  of  the  sick  even  though  they  be 
sick  of  infectious  disease. 

But  the  mechanism  for  even  this  function,  al- 
though it  is  actually  in  existence,  actually  organ- 
ized, actually  authorized,  actually  operating,  and 
has  behind  it  long  years  of  legal  precedence  and 
the  support  of  public  opinion,  is  sadly  under- 
manned, and  under-equipped, — merely  a  skele- 
ton. 

IMMEDIATE  POSSIBILITIES 

It  is  true  that  even  those  advanced  states  which 
have  organized,  in  part  or  in  whole,  the  above 
outlined  operations,  organized  the  control  of  in- 
fectious disease  far  earlier  and  more  completely 
than  they  organized  any  of  the  others.  They 
have  done  so  in  accordance  with  a  general  rule, 
which  governs  all  mankind,  namely,  that  of  doing 
first  the  simplest,  crudest,  and  most  obviously 
necessary  thing. 

But  it  is  also  a  matter  of  fact  that  the  super- 
vision of  infectious  persons  differs  essentially  in 
principles,  methods,  object,  extent  of  applica- 
tion, and  destiny  from  education  in  personal 
hygiene,  medical  supervision  for  defects,  or  medi- 
cal treatment.  The  latter  are  obviously,  directly, 
and  immediately  to  and  for  the  benefit  of  the  in- 
dividual who  is  educated,  supervised,  or  treated. 
In  principle,  they  are  gifts  of  the  state  to 
its  individual  citizens.  But  the  former  is  not 
to  the  benefit,  usually  rather  to  the  temporary 
detriment,  of  the  individual  who  comes  under  its 
operation.  Its  benefits  are  wholly  to  others,  and 
even  so  do  not  add  anything  to  their  welfare, 
but  merely  prevent  subtraction  from  it. 

The  methods  of  the  infectious-disease  super- 

30 


visor  are  necessarily  those  of  the  detective  ana 
the  pohceman,  not  those  of  the  educator  or  the 
physician.  The  object  he  seeks  is  prevention, 
not  construction  or  even  repair.  He  does  not  deal 
equally  with  every  citizen  for  that  citizen's  good, 
as  does  the  educator  or  the  physician,  but  he  fer- 
rets out  a  few  individuals  who  must  be  restrained 
for  the  good  of  the  others.  His  destiny  is,  if 
successful,  to  eliminate  the  only  reasons  for  his 
own  official  existence,  while  the  educator  and 
the  medical  supervisor  for  defects  will  always 
continue  to  find  in  each  new  annual  crop  of  chil- 
dren a  new  and  constantly  increasing  field  for 
their  services. 

In  brief,  the  first  three  activities  are,  like 
boards  of  public  works,  constructional  in  essence. 
Supervision  of  infection  is  like  the  work  of  fire 
departments,  conservative  merely.  ' 

But  although  we  may  accept  these  four  items 
as  entirely  proper  for  ultimate  realization,  we 
must  acknowledge  that  the  present  public-health 
situation  cannot  be  met  merely  by  handing  this 
outline  to  the  state  and  asking  that  it  be  put  into 
efifect.  Still  less  can  it  suffice  to  hand  the  out- 
line over  to  existing  boards  »of  health  or  health 
departments,  notwithstanding  that  these  consti- 
tute, by  tradition  and  precedent,  practice  and  or- 
ganization, that  arm  of  the  government  to  which 
has  been  assigned  the  only  activities  of  the  state 
in  relation  to  bodily  welfare,  so  far  seriously  dr 
widely  recognized. 

Health  departments  in  general  are  under- 
manned, under-equipped,  continually  distracted 
with  futilities.  But  if  expanded,  their  distrac- 
tions eliminated,  and  their  faces  set  sternly  to 
the  reduction  of   disease  and  death,  they  could 

31 


not  at  once  assume  all  the  items  of  this  program. 
Why? 

Item  No.  3  we  may  dismiss  from  consideration 
at  present.  It  is  out  of  the  question  for  many 
years  to  come. 

For  Item  No.  1  the  basic  necessities, — knowl- 
edge, authority,  and  organization, — are  all  lack- 
ing. For  Item  No.  2  knowledge,  authority  and 
equipment  can  be  had,  it  is  true,  although  they 
may  not  be  immediately  available.  For  Item  No. 
4  only  have  we  nozu  all  three, — knowledge,  au- 
thority, and  equipment,  although  the  latter  only 
in  outline. 

EDUCATION 

Furthermore/  it  is  true  that  Item  No.  1,  the 
education  of  every  citizen  in  personal  hygiene, 
cannot  be  carried  out  praperly  (apart  from  the 
infections  diseases)  by  any  organization  at  the 
present  time.t 

Why?  Because  such  education  requires,  first, 
the  knowledge,  digestion,  and  formulation  of  the 
facts  to  be  taught;  and,  second,  the  training  of 
those  who  are  to  do  the  teaching. 

But  the  best  of  us  do  not  know  personal  hy- 
giene (apart  from  the  infectious  diseases)  ;  that 
is,  we  do  not  know  how  to  care  for  and  operate 
the  human  body  as  a  machine.  What,  for  in- 
stance, should  be  taught  concerning  diet  when 
Chittenden  of  Yale  and  Wiley  of  Washington 
promulgate  exactly  opposite  views?  What  should 
be  taught  concerning  ventilation  when  the  whole 
subject  is  in  absolute  chaos?  What  should  be 
taught  concerning  clothing,  sleep,  exercise,  and 
fatigue  ? 

(Our  physiologists  study  the  normal  body,  but 
more  in  relation  to  disease  than  to  healtl'k  Our 
vital  statisticians  seek  the  factors  of  morbidity, 

32 


not  of  physical  perfection.  Even  the  famous 
Federal  "poison  squad"  sought  to  determine 
what  is  bad  for  people  to  eat,  not  what  is  good 
for  them.  All  of  these  things  are,  of  course,  use- 
ful, excellent,  even  essential  to  know ;  but  they  do 
not  teach  us  personal  health,  they  teach  only  the 
avoidance  of  actual  Hisease. 

The  truth  is,  that,  as  regards  human  bodily 
welfare,  personal  hygiene  proper,  we  know  but 
one  factor,  that  is  disease.  We  know  disease  be- 
cause we  have  studied  it.  We  know  also  the 
"personal  hygiene"  of  farm  animals  because  we 
have  studied  the  "personal  hygiene"  of  farm 
animals,  at  a  cost  of  twelve  million  dollars  a 
year.  But  we  know  nothing  of  the  personal 
hygiene  of  human  citizens,  because  we  do  not 
study  it  at  all,  except  the  hygiene  of  infants. 
We  shall  never  know  the  personal  hygiene  of 
humans,  apart,  always,  from  the  infectious  dis- 
eases, until  we  do  study  it — until  we  put  as  much 
time,  pains,  and  money  into  it  as  any  agricultural 
experimental  station  in  any  state  puts  into  the 
study  of  the  "personal  hygiene"  of  cows  and 
hogs. 

There  is,  however,  no  real  reason  why  health 
departments   should   teach   personal    hygiene   at     J 
all,  apart  from  the  infections  diseases,  any  more 
than  that  they  should  teach  personal  morals  oi^j 
personal  finance.     Health  departments  have  no  i 
peculiar  knowledge  of  the  one  any  more  than  of 
the   others ;  and  if  they  had,   there  are  profes^, 
sional  teachers  much  more  competent  and  pos- 
sessing far  greater  facilities  than  any  health  de-  ) 
partment.  / 

Even  education  concerning  infectious  diseases 
is  not  strictly  health-department  work.  This, 
like  personal  hygiene,  should  be  taught  seriously 

33  ♦ 


and  systematically  in  the  public  schools.  Ninety 
per  cent  of  the  population  never  enter  high 
schools,  and  only  one  per  cent  reach  the  univer- 
sity. Whatever  of  personal  hygiene  or  prevent 
tion  of  infection  the  citizen  should  know,  must 
be  taught  in  the  grades  or  miss  its  mark.  No 
amount  of  desultory  pamphleteering  or  lecturing 
by  health  departments  can  ever  take  the  place  of 
properly  conducted  grade  courses.  Unlike 
courses  in  personal  hygiene,  about  which  we  know 
next  to  nothing,  courses  in  the  prevention  of 
infection  could  be  established  at  once,  since  we 
know  almost  all  about  it ;  but  it  is  no  part  of 
health-department  work  to  conduct  such  courses. 
Health  departments  are  police  bodies,  not  preach- 
ers or  teachers.  They  may  well,  it  is  true,  edu- 
cate the  educators.  There  is  no  reason  why  they 
should  educate  the  public,  except  the  failure  of 
the  professional  educators  to  do  so. 

MEDICAL  SUPERVISION  OF  SCHOOLS 

Medical  supervision  of  school  children,  so  far 
as  it  deals  with  defects,  deals  with  non-trans- 
missible conditions.  ^ledical  supervision,  so  far 
as  it  deals  with  infection,  deals  with  transmis- 
sible conditions.  The  latter  therefore  detects 
links  in  the  chain  of  the  ramifying  threads  of 
infection  throughout  the 'community, — a  ramifica- 
tion, the  threads  of  which  unquestionably  should 
be  in  health-department  hands. 

But  medical  supervision  for  infectious  disease 
in  school  as  a  means  for  general  control  of  all 
infections  has  had  a  singularly  exaggerated  im- 
portance attached  to  it.  Only  one-half  of  the 
state's  children  attend  school  in  any  one  year, 
and  even  the  school  child  passes  but  one-ninth 
of   each   year   in   school.     Were   health   depart- 

34 


ments  alert  in  their  familiarity  with,  and  effi- 
cient in  their  control  of,  the  ramifications  of  the 
chains  of  infection  outside  of  the  schools,  they 
would  locate  and  supervise  the  infective  child 
before,  not  after,  he  had  infected  school  chil- 
dren ;  before,  not  after,  the  medical  supervisors 
for  defects  discovered  him  in  the  class-room. 

But  the  fact  that  medical  supervision  for  de- 
fects need  never  encounter  infection  in  that  one- 
fourth  of  the  total  population  which  is  contained 
in  the  schools,  if  health  departments  do  their 
work  properly  in  the  other  three-fourths  which  is 
outside  of  the  schools,  carries,  alas,  no  guarantee 
that  infective  children  will  not,  for  a  long  time  to 
come,  occupy  a  share  of  the  medical  school 
supervisors'  attention.  Especially  will  this  be 
true  in  rural  districts  where  nearly  two-thirds 
of  the  children  secure  their  education  and  where 
health-department  organization  and  equipment  is, 
practically  speaking,  non-existent. 

Hence,  whatever  may  be  our  individual  views 
with  regard  to  the  ultimate  relation  of  medical 
school-supervision  for  defects  to  supervision  of 
infectious  persons,  we  need  not  blind  ourselves 
to  the  fact  that  ideal  conditions  are  far  in  the 
future,  and  that  immediate  necessities  call  for 
immediate  adjustments  which  may  be  temporary 
or  not,  depending  on  future  developments. 

Mei^iea4--&upervi6iQn  for  defects  and  medical 
supervision  for  infection  are  now,  and,  for  some 
time  to  come,  must  rerriain,  so  interdependent 
that  the  closest  co-operation,  even,  in  the  rural 
districts,  amalgamation,  will  be  necessary.  Such 
amalgamation  should  be  under  health  depart- 
ments, wherever  that  is  possible,  rather  than 
under  school  boards. 
1    First,  because  school  boards  have  no  authority 

'  35  , 


from  tradition,  by  precedence  or  by  law,  as  have 
health  departments  to  follow,  outside  of  the 
schools,  the  ramifications  of  infection  of  which. 
the  infective  child  in  the  schools  constitutes  but 
one  link,  nor  even  to  follow  that  one  link  back- 
to  its  home. 

Second,  because  school  boards  have  no  infor- 
mation or  authority  concerning  the  full  half  of 
the  children  who  are  not  of  school  age  nor  con- 
cerning any  adult  except  those  directly  connected 
with  the  schools. 

Finally,  amalgamation  in  the  rural  districts  is 
essential  for  one  great  reason,  if  for  no  other, 
and  this  reason  is  that  if  we  do  not  conibine 
both  functions  in  one,  in  the  rural  districts,  we 
shall  not  secure  either  function  there  at  all. 

SUMMARY 

Non-infectious  diseases,  disabilities,  and  de- 
fects constitute  a  field  for  governmental  atten- 
tion as  great  as  or  greater  than  do  the  infectious 
diseases. 

There  are  no  theoretical  reasons  why  govern- 
ments should  not  concern  themselves  with  the 
greater  (the  non-infectious  group),  as  well  as 
with  the  lesser   (the  infectious  group). 

Public-health  activitieKjn  their  very  broadest 
conception  would  include  "ai-k  the  functions  of 
government,  since  there  is  nothing  of  interest 
to  man,  from  high  finance  to  municipal  play- 
grounds, which  has  not  some  relation  to  health. 

But  an  administrative  system  so  vast  as  to 
control  all  human  activities  related  to  health, 
would  merely  replace  the  government,  and  would 
itself  be  necessarily  subdivided,  nuicli  as  exist- 
ing governments  are  now. 

It  is  not  difficult  to  outline  a  logical  program 

86 


for  one  branch  of  any  government,  a  branch 
which  should  deal  with  the  bodily  welfare  of  man 
and  include  hygienic  education,  medical  super- 
vision, medical  treatment,  and  the  suppression  of 
infectious  diseases. 

But  there  are  many  practical,  as  well  as  theo- 
retical, reasons  why  health  departments  will  not, 
indeed  cannot,  proceed  at  once  to  put  this  pro- 
gram into  execution.  Concerning  education  in 
personal  hygiene,  apart  from  the  infectious  dis- 
ease, agreement  as  to  the  basic  facts  to  be  taught 
has  yet  to  be  reached.  As  to  the  second  and  third 
items,  organization,  broad  precedent,  and  broad 
authority  are  all  lacking. 

Concerning  the  infectious  diseases,  and  con- 
cerning them  only,  are  the  paths  clear  and  the 
duties  plain. 

The  "instant  need  of  things"  is  to  do  faithfully 
and  well  that  one  duty  which  we  fully  under- 
stand, the  only  one  for  which  organization,  au- 
thority, tradition,  precedent,  and  the  support  of 
public  opinion  are  already  in  our  hands,  i.  e.,  the 
abolition  Qi-w4f><44fwf^  diseases.  To  this  end,  the 
embryonic  beginnings  of  the  medical  supervision 
of  every  citizen — that  is,  medical  school-super- 
vision^should  lend  its  aid,  especially  in  the  rural 
districts. 

But  until  we  have  accomplished  this — the  sim- 
plest^ easiest,  crudest  of  our  obvious  and  recog- 
nized duties — that  one  which  lies  right  at  our 
finger-tips,  we  cannot  very  well  ask  that  the 
Nation  should  hand  over  to  health  departments 
all  its  great  problems  of  life,  death,  health,  and 
national  development. 

/To  achieve  the  abolition  of  infection  we  must 
strip  for  action,  discard  all  useless  armor  and 
antiquated    weapons,    cease   desultory   bombard- 

37 


ment  at  leisurely  long  range  of  the  enemy's  out- 
lying domains,  and  personally  seek,  with  well- 
shortened  weapons,  the  enemy  himself  (infec- 
tion) in  his  real  stronghold  (the  infective  per- 
son). 


as 


Chapter  IV 
THE  OLD  PRACTICE  AND  THE  NEW 

EPIDEMIOLOGY 

The  previous  chapters  were  designed  to  clear 
the  way  for  the  constructive  program  which  the 
following  articles  will  seek  to  set  forth. 
j      The    conclusion    so    far    reached    is    that    the 
chief  immediate  duty  of  official  public  health  is 
the  abolition  of  all  the  infectious  diseases.     For 
this  ^great   enterprise,   both   scientific   principles 
and   scientific  practice  are  essential.     The  new 
'    public  health  principles  have  been  outlined ;  the 
I   new    public   health   practice    remains"  to   be   ex- 
plained. 

Public  health  practice  in  handling  infectious 
diseases  mav*be  traced  through  three  distinct 
eras :  past,  present,  and  future. 

Past,  or  era  of  ''general  sanitation." — The 
practice  consisted  in  a  strenuous  campaign  of 
"general  cleaning  up" ;  an  orgy  of  sweeping, 
burning,  scrubbing;  an  ecstacy  of  dirt-destruc- 
tion, individual,  household,  municipal."*' 


*The  reader  is  begged,  pleaded  with,  besought,  not 
to  repeat  at  this  point  the  wearisome  old  gibe.  Then 
you  want  us  to  live  like  pigs?  If  not,  why  do  you 
condemn  "general  sanitation?"  We  do  not  condemn 
"general  sanitation,"  or  cleanliness,  or  order,  or  de- 
cency. We  simply  present  the  scientific  fact  that  these 
things  do  not  greatly  prevent,  nor  does  their  absence 
produce,  infectious  diseases.  They  have  a  thousand 
advantages,  but  not  this  one.  Honesty  does  not  pro- 
tect against  lightning;  yet  this  fact  can  not  affect  a 
single  honest  man,  nor  does  its  statement  detract  from 
honesty  in  the  least.  And  so  with  "general  sanita- 
tion." It  is  specific,  not  "general,"  cleanliness  that 
prevents    infection. 

39 


This  "general  sanitation"  was  a  true  old-style 
shot-gun  prescription  used  indiscriminately,  for 
any  outbreak  of  any  disease.  No  distinction  of 
sources  from  routes  of  infection  was  made ;  in- 
deed, that  a  distinction  existed  was  hardly  rec- 
ognized, and,  looking  back,  it  sometimes  seems 
that  even  the  most  obvious  relations  of  cause  and 
effect  often  were  ignored. 

Present,  or  era  of  ''specific  sanitation.'' — The 
practice  is  deliberately  to  analyze  the  particular 
outbreak  of  the  particular  disease  concerned ; 
speedily  to  determine  thus  the  exact  route  of  in- 
fection actually  responsible ;  and  promptly  to 
abolish  or  block  that  route. 

Future,  or  era  of  "supervision  of  sources." — 
The  practice,  so  far  as  it  is  possible  to  forecast 
it,  will  be  the  location  and  supervision  of  the 
sources  of  infection  (infected  persons)  before, 
not  after,  they  gain  access  to  routes,  so  in  time 
eliminating  infectious  diseases  entirely. 

Thus  it  is  seen  that  public  health  practices, 
past,  present,  and  future,  form  a  series,  descend- 
ing from  the  general  to  the  particular,  from  the 
surroundings  to  the  individual,  from  (a)  the 
random  application  of  blanket  measures,  through 
(b)  a  specific  detection  and  a  specific  correction 
of  a  specific  bad  condition,  to  (c)  the  actual  fore- 
stalling of  the  development  of  such  conditions  at 
all. 

COMPARATRE   METHODS 

To  make  clear  this  most  important  matter  of 
public,  health  practice,  illustrations  are  offered, 
exhibiting  the  public  health  practices  of  the 
different  eras  in  action  in  the  face  of  a  typhoid 
fever  epidemic,  typhoid  being  selected  because 
abolishing  this  one  disease  alone  involves  every 

40 


modern  public  health  principle,  and,  in  some 
form,  every  modern  public  health  practice. 

The  end  sought  was,  is,  and  always  will  be, 
the  same, — to  stop  the  spread  of  the  disease. 

But  the  methods  of  the  dififerent  eras  contrast 
widely. 

In  the  past  era  of  'VenpraJ__saiiitation,''  a  ty- 
phoid epidemic  was  met  by  a  vigorous  attack  on 
dirt,  damp  cellars,  dust,  disorder;  on  garbage, 
manure,  dead  ajiimals,  weeds,  defective  plumb- 
ing, and  stagnant  pools ;  cobwebs  were  cleared 
away ;  windows  were  opened  to  'iet  in  the  blessed 
sunshine"  ;  preachers  preached  cleanliness  ;  teach- 
ers 'taught  bathing ;  health  officers  limed  back 
alleys  and  whitewashed  outhouses.  Human  na- 
ture demanded  ''action,"  and  "action,"  of  a  kind, 
was  supplied. 

We  know  now,  what  they  did  not  know  then, 
that  typhoid  infection  is  carried  by  water,  food, 
flies,  milk,  and  contact,  and  that  "general  clean- 
ing up"  could  not  remove  infection  from  pollut- 
ed water-mains,  or  purify  a  contaminated  milk 
supply ;  could  not  stop  the  eating  of  infected 
food  or  eliminate  contact  infection.*  The  only 
form  of  typhoid  which  "general  sanitation" 
could  greatly  affect  was  that  due  to  flies. f     But 

*Contact  infection  is  the  infection  which  radiates 
directly  from  the  infected  person  through  nose  and 
mouth  and  bladder  and  bowel  discharges.  The  hands 
of  the  Infector  and  of  his  associates  are  the  chief  car- 
riers of  all  these  discharges,  although  mouth-spray 
and  sputum  also  act  in  many  diseases.  Things  directly 
infected  by  these  discliarges  are  also  dangerous,  but 
practically  only  while  the  discharges  remain  fresh  and 
moist.  The  radius  of  action  of  contact  is  usually 
small;  it  compares  with  the  radius  of  action  of  water, 
food,  flies,  and  milk  somew^hat  as  a  bayonet  with  a 
gatling  gun  in  a  general  melee.  But  contact  infection 
in  the  long  run  is  more  deadly  than  other  routes,  for 
to  each  one  such  "gatling  gun"  there  are  many 
"bayonets." 

tWe  do  not  now  use  "general  sanitation"  even  for 
fly  outbreaks.  From  this  old  shot-gun  prescription  we 
have  eliminated  all  the  ingredients  but  one,  that  one 
which  alone  was  active.  In  fly  outbreaks  w^e  exclude 
flies  from  infected  discharges,  and  (so  far  as  the  pri- 
mary outbreak  is  concerned)  then  stop.  So  does  the 
outbreak. 

41 


of  course  the  fly  was  not  then  known  as  a  route 
of  infection  in  typhoid,  so  that  even  the  results 
that  ''general  sanitation"  secured  were  secured 
largely  by  accident,  i.  e.,  by  the  unknown  con- 
junction of  an  unrecognized  cause  with  an  un- 
premeditated cure. 

The  present  era  of  "specific  sanitation"  began 
a  decade  or  so  ago.  Water,  food,  flies,  and  milk 
have  been  fully  recognized  as  the  main  public 
routes  of  typhoid  infection ;  contact,  especially 
of  late,  as  the  great  private  route.  Outbreaks 
have  been  met  by  finding  the  particular  route 
involved,  and  by  abolishing  or  blocking  that 
route.  But  even  in  this  era,  the  earlier  practice 
for  the  attainment  of  this  end  differed  funda- 
mentally from  that  of  today- 

The  earlier  epidemiologistsj  of  this  era  ar- 
gued thus :  "Water,  food,  flies,  and  milk  are 
the  known  public  routes ;  usually  some  one  of 
these  routes  is  responsible  in  each  outbreak. 
Therefore,  to  find  the  responsible  route  in  any 
given  instance,  flood  the  stricken  community 
with  trained  inspectors ;  analyze  the  water  sup- 
plies ;  investigate  the  milk  supplies ;  go  through 
the  markets ;  delve  into  the  provision  stores ;  es- 
timate the  number  of  flies,  and  locate  their  breed- 
ing-places ;  survey  the  back  alleys  and  out-door 
toilets ;  plat  all  results  on  maps ;  interview  the 
city  engineer,  the  fire  marshal,  the  meat  and 
milk  inspectors,  and  examine  their  official  rec- 
ords ;  secure  the  morbidity  and  mortality  records 
of  the  board  of  health ;  study  all  available  me- 
teorological, topographical,  geological,  and  oth- 
er data ;  in  brief,  probe,  dissect,  tabulate,  collate, 
and  compare  all  *  possible .  physical  information 
concerning  the  community.     Under  such  inquisi- 

tExperts  on  epidemics. 

42 


tion  the  guilty  route  of  infection  can  scarcely 
escape  detection. "1j 

For  these  methods  it  must  be  said  that  they 
were  scientific,  logical,  and  exhaustive ;  but  they 
were  terribly  laborious  and  generally  exceeding- 
ly slow.  Of  course  it  sometimes  happened  that 
the  guilty  route  of  infection  was  stumbled  on 
at  once ;  and  almost  always  this  end  was  reached 
sooner  or  later,  too  often,  however,  only  after 
weeks,  months,  or  even  years  of  effort.  Their 
ponderous  slowness  took  these  methods  out  of  the 
class  of  effective  emergency  measures,  and  this 
was  recognized  even  then,  for  typhoid  investiga- 
tion was  not  considered  a  matter  of  haste,  in 
initiation  or  in  execution. 

These  earlier  methods  paralleled  somewhat 
those  which  we  might  suppose  an  amateur  hunt- 
er to  use,  if  he  were  commissioned  to  find  a  cer- 
tain sheep-killing  wolf.  Confronted  with  this 
problem,  the  amateur  might,  not  unreasonably, 
flood  the  surrounding  mountains  with  assistants, 
instructing  them  to  find  all  the  existing  wolf- 
trails,  and  to  follow  each  such  trail  inward 
towards  the  slaughtered  sheep  until  satisfied  that 
it  did,  or  did  not,  actually  lead  to  them. 

The  methods  of  today  are  the  exact  converse 
of  these.  Instead  of  finding  in  the  mountains 
and  following  inward  from  them,  say,  500  dif- 
ferent wolf  trails,  499  of  which  must  necessarily 
be  wrong,  the  experienced  hunter  goes  directly 
to  the  slaughtered  sheep,  finding  there  and  fol- 
lowing outward  thence  the  only  right  trail, — the 
only  trail  that  is  there, — necessarily  the  trail  of 
the  guilty  wolf. 

'\J  THE    NEW    EMERGENCY    EPIDEMIOLOGY 

The  epidemiologist  of  today,  called  to  a  ty- 
jhoid-stricken   community,   at  first  pays  no   at- 

43 


tention  to  the  physical  condition  of  the  existing 
possible  routes.  It  is  sociological  data,  not 
physical,  that  he  needs  at  this  stage.  He  knows 
that,  counting  the  wells,  the  toilets,  the  milk 
supplies,  etc..  there  may  be  500  of  these  possible 
routes ;  but  he  does  not  go  to  see  them,  nor  even 
the  pumping-station  or  the  sewage-outfall.  He 
goes,  hot-foot,  straight  to  the  "slaughtered 
sheep" — straight  to  a  patients  bedside.  There, 
in  thirty  minutes,  lie  reduces  the  500  possibili- 
ties to.  say.  10.  i.  e..  to  those  encountered  (a) 
by  this  f^aticiir^  (b)  at  a  ccrtaiti  titnc  (the  date  of 
his  infection).  These  10  are  carefully  listed: 
but  the  epidemiologist  does  not  investigate  even 
these  10.  He  goes,  instead,  straight  to  another 
bedside  and  lists  there  the,  say.  10  routes  that 
constitute  the  possible  routes  for  this  second  pa- 
tient ;  but  he  does  not  investigate  the  routes  on 
this  list  either :  he  merely  eontpares  the  tzco  lists. 
Why?  Because  the  one  guilty  route  must  be 
on  i?oth  lists.  Thus  if  both  lists  show  the  same 
water  supply,  that  water  supply  remains  a  pos- 
sible guilty  route :  but,  if  not,  zcater  is  eliminat- 
ed. If  both  lists  show  the  same  milk  supply, 
that  milk  supply  remains  a  possible  guilty  route : 
but.  if  not.  milk  is  eliminated.  Discarding  thus 
tlie  routes  not  common  to  both  lists,  5  routes, 
say.  still  remain.  At  the  third  patient's  bedside 
these  5  are  reduced  bv  similar  treatment,  to  sav. 
3.  So  the  search  goes  on  until  he  either  locates 
the  one  main  public  route  common  to  all  or 
proves  that  the  outbreak  is  not  due  to  such  a 
public  route  at  all,  but  to  the  private  routes  ex- 
tending directly  from  person  to  person,  i.  e..  to 
contact.     Often   in  twelve  hours  of  such  work, 

*Of  course  imported  and  secondary  cases  are  not 
used  for  this  purpose,  and  at  this  staare  the  epidemi- 
ologrist  is  most  careful  to  eliminate  all  such  from  his 
tabulations. 


£Tenerall\-  in  twenty- four,  almost  always  in  thirtv- 
six,  the  evidence  is  conclusive.  The  guilty  route 
stands  out  convicted ;  for  it  is  found  on  every 
list,  and  the  innocent  routes  are  exonerated,  for 
they  occur  only  on  some.''' 

Now^  at  last,  and  not  till  now,  does  the  epi- 
demiologist deal   directly  with  the  route  of  in-l 
fection   thus   indicated,   examine   it   to   find   justi 
how  it  is  responsible,  and  thus  provide  the  ini- 
tial data  for  its  remedy. f 

It  is  at  the  point  when  the  guilty  public  route 
is  shown  (if  public  route  there  be)  that  the 
epidemiologist,  so  far  as  this  public  route  is  con- 
cerned, steps  out,  and  the  bacteriologist,  the 
chemist,  the  sanitary  engineer  step  in ;  one,  or 
any  two,  or  all  three,  as  conditions  may  require. 

But  detecting  and  demonstrating  the  guilt  of 
a  main  public  route,  when  such  is  involved,  by 
no  means  ends  the  epidemiologist's  duties.  The 
work  outlined  so  far  is  required  (in  Minnesota) 


♦Obviously  this  method  fails  if  there  be  but  one 
patient,  foi*  then  comparison  of  lists  is  of  course  im- 
possible; but  single  cases  usually  prove  to  be  imported 
or  from  contact.  Also  it  may  happen  that  even  three 
or  four  patients  do  not  furnish  sufficient  data  to  nar- 
row the  possible  routes  to  one;  obviously,  the  more 
patients  there  are  the  more  conclusive  the  results. 
But  even  when  only  a  few  patients  exist,  this  method 
reduces  the  number  of  routes  to  be  investigated  to 
say,  10,  often  to  2  or  3,  an  immense  reduction  from  the 
original  500. 

tTo  those  who  are  not  familiar  with  modern  public 
health  work,  this  account  may  seem  incredible  or  at 
least  exaggerated,  yet  these  are  the  regular  proce- 
dures of  emergency  epidemiology  wherever  they  are 
understood  today.  Records  of  such  work  in  Minnesota 
for  years  back  are  open  to  all  enquirers.  Moreover, 
the  above  account  has  pictured  the  epidemiologist 
working  vmder  a  most  disadvantageous  condition,  i.  e., 
in  complete  ignorance  of  the  community  he  deals  with, 
except  for  what  he  learns  during  the  investigation  it- 
self. If  previous  familiarity  with  the  affected  com- 
munity exists,  the  main  public  route  of  infection  can 
often  be  determined  without  leaving  headquarters, 
provided  merely  that  correct  data  as  to  the  number, 
location,  and  dates  of  infection  of  the  cases  are  sub- 
mitted. Of  course  such  "long-distance  epidemiology," 
wonderfully  accurate  though  it  can  be  made,  does  not 
compare  in  reliability  or  in  finish  of  detail  with  actual 
personal  investigation  on  the  ground. 

45 


chiefly  in  typhoid  outbreaks ;  and  then  chiefly 
in  those  typhoid  outbreaks  which  are  derived 
from  water,  food,  flies,  or  milk.  The  work  still 
to  be  done  is  required  in  all  typhoid  outbreaks, 
whether  initially  derived  from  these  public  routes 
or  from  contact ;  moreover,  it  is  called  for  in  the 
majority  of  outbreaks  of  all  the  other  infec- 
tious diseases,  because  the  majority  are  usually 
contact  outbreaks  at  all  stages.  That  work  is 
the  prevention  of  further  spread  by  contact. 

To  understand  this  clearly,  it  must  be  re- 
membered that  under  present  conditions  every 
typhoid,  or  other,  epidemic  which  begins  from 
some  one  public  route  (water,  food,  flies,  or 
milk)  soon  presents  two  distinct  parts;  the  pri- 
mary outbreak,  consisting  of  those  persons  who 
received  their  infection  from  that  public  route, 
and  the  secondary  outbreak,  consisting  of  those 
persons  who  later,  by  the  private  routes  of  con- 
tact, receive  their  infection  directly  from  the  first 
set.  Those  typhoid,  or  other,  epidemics  which 
begin  from  the  private  routes  of  contact  do  not, 
of  course,  present  a  ''primary"  outbreak  at  all. 
They  are,  so  to  put  it,  "secondary"  outbreaks 
from  the  outset. 

The  search  for  a  public  route  is  therefore  only 
the  first  step  in  subduing  any  epidemic.  If  such 
route  exist,  this  step,  by  finding  it,  provides  for 
getting  rid  of  it,  which  prevents  the  infection  of 
any  more  persons  from  that  route,  and  so  ends 
the  primary  outbreak.  But  this  first  step  by  no 
means  ends  the  epidemic  as  a  whole,  for  the  per- 
sons already,  infected  from  that  public  route  con- 
stitute each  one  a  source  of  further  spread  by 
contact,  a  spread  which,  of  course,  must  also  be 
prevented.  Obviously,  epidemics  which  are  con- 
tact epidemics  throughout,  necessarily  present 

46 


an  identical  problem  from  this  standpoint,  for 
every  existing  infected  person,  whatever  the 
route  of  his  infection,  is  a  separate  danger,  and 
each  requires  supervision.* 

FINDING  THE   UNKNOWN   CASES 

How  does  the  prevention  of  contact  infection 
depend  on  epidemiology?  Cannot  the  spread  of 
infection  by  contact  from  knozvn  cases  be  guard- 
ed against  by  the  attendants  (nurses  and  physi- 
cians) which  each  such  knozvn  case  necessarily 
has  ?  True,  and  were  these  knozvn  cases  the 
only  danger-points  proper  attention  to  prevent- 
ing spread  from  them  would  be  all-sufficient. 
But  the  knozvn  cases  usually  form  but  half  of 
the  danger-points  because  only  half  of  the  dan- 
gerously infected  persons  become  knozvn  cases. 
The  other  half  consists  of  "missed  cases"  (mild, 
unrecognized,  and  concealed  cases,  early  cases, 
and,  later  on,  convalescing  cases)  and  of  "car- 
riers." (The  "carriers"  are  infected  persons, 
capable  of  infecting  others,  but  not  themselves 
made  ill  by  the  disease  germs  which  they  never- 
theless carry  and  distribute.) 

Missed  cases  and  carriers,  unless  especially 
sought  for,  are,  and  remain,  unknown  and  unlo- 
cated ;  they  have  no  known  attendants  to  whom 
the  prevention  of  spread  of  infection  from  them 

*In  earlier  days  the  fallacy  that  typhoid  fever  pa- 
tients could  not  directly  infect  their  associates — in 
brief,  that  typhoid  fever  was  not  contag-ious — was  re- 
sponsible for  the  long--delayed  recognition  of  second- 
ary typhoid  outbreaks,  even  after  the  origin  of  pri- 
mary outbreaks  had  been  learned  and  methods  of  deal- 
ing with  them  perfected.  We  know  now  that  abolish- 
ing or  blocking  a  primary  route  is  but  half  the  story. 
The  primary  cases,  if  neglected,  may  continue  to  in- 
fect other  persons  by  contact,  and  these  again  others, 
ad  infinitum.  Such  secondary  outbreaks  may  extend 
slowly  for  months  or  years  and  yield  cases  equaling 
or  exceeding  in  number  those  from  the  primary  out- 
break. The  "endemic  typhoid"  of  some  localities  is  at 
times  an  unrecognized,  slow-moving,  secondary  out- 
break. 

47 


can  be  entrusted ;  they  g-enerally  do  not  know 
themselves  to  be  infected;  and,  if  ignored,  they 
are  more  dangerous,  because  inevitably  un- 
guarded, ,than  the  known  cases,  for,  being 
known,  the  latter  can  be  guarded. 

This  problem,  the  finding  of  missed  cases  and 
carriers,  is  solved  by  an  epidemiological  proce- 
dure which,  while  less  spectacular,  is  far  more 
widely  useful  than  that  of  finding  public  routes, 
because  it  applies,  not  alone  to  contact-typhoid 
outbreaks,  but  to  all  contact  outbreaks,  that  is,  to 
all  infectious  diseases,   from  tuberculosis  down. 
Were  the  ability  to  find  public  routes  of  infec- 
tion in  water,  food,  fly,  and  milk  outbreaks  the 
only  virtue  of  epidemiology,   its   services  could 
have  no  value  in  the  great  mass  of  infectious  dis- 
ease  for  the  great  mass  arises  chiefly  by  con-/ 
tact.     It  is  the  ability  to  find  the  private  sources^ 
of  infection  in   contact    outbreaks    that    makes   J 
epidemiology  the  pivotal  factor  of  modern  pub-/ 
lie   health.. 

This  location  of  missed  cases  and  carriers  in 
typhoid,  and  other,  outbreaks,  is  called  concur- 
rent epidemiology,  and  is  well  worth  thoroughl\ 
understanding. 

SUMMARY 

Modern  public  health  practice  for  the  control 
of  infectious  diseases  consists,  not  in  the  physi- 
cal surveillance  of  whole  communities,  but  in 
the  sociological  study  of  the  infected  persons  in 
them. 

This  practice  is  best  illustrated  in  the  modern 
handling  of  typhoid  fever  epidemics,  because 
this  disease  is  all-inclusive,  i.  e.,  it  travels  by  all 
four  of  the  great  public  routes  (water,  food,  flies, 
and  milk),  as  well  as  by  the  private  fifth  route, 

4S 


contact ;  also  because  typhoid  is  an  intestinal  in- 
fection and,  of  all  the  infectious  diseases  of  the 
temperate  zone,  the  intestinal  infections  alone 
travel  by  all  of  these  five  great  routes. 

A  typhoid  epidemic  is  approached,  as  is  any 
other  epidemic,  first,  to  determine  if  any  public 
route  of  infection  is  involved,  and,  if  so,  what 
that  route  is  and  how  it  operates,  thus  finding 
how  to  stop  it;  second,  to  determine  the  private 
routes  and  sources  of  the  contact  outbreak  which, 
sooner  or  later,  exists  in  all  epidemics,  whether 
the  original  route  be  a  public  route  or  not. 

To  the  epidemiologist,  the  public  health  de- 
tective, falls  both  these  crucial  tasks.  It  is  his 
function  to  find  those  underlying  facts  which 
alone  can  form  a  sound  basis  for  real  remedial 
measures. 

How  he  performs  the  finding  of  public  routes 
has  been  described ;  the  finding  of  private  routes 
and  sources  will  be  described  later.  In  both 
procedures  the  initial  step  is  the  same,  namely, 
the  investigation  of  the  known  cases.  By  seeing 
and  questioning  knozvn  cases,  or  their  imme- 
diate relatives  and  attendants,  the  epidemiologist 
can  classify  them  into  native  and  imported.  The 
native  cases,  since  they  alone  originated  in  the 
community  under  investigation,  are  further  clas- 
sified into  primary  and  secondary  cases.  From 
the  histories  of  the  primary  cases,  if  such  there 
be,  he  learns  the  public  route.  From  all  the 
cases,  imported,  primary,  and  secondary,  he  ob- 
tains the  data  needed  for  the  next  step. 


49 


THE  NEWEST  PRACTICE 


Chapter  V 


•if. 


CONCURRENT   EPIDEMIOLOGY 

The  preceding  chapter  outlined  the  first  step  in 
the  modern  handling  of  a  typhoid  fever  epidemic, 
typhoid  fever  being  selected  because  its  proper 
handling  illustrates  best  the  principles  and  practice 
of  modern  public  health  work. 

The  first  step  is  the  discovery,  by  the  methods  of 
emergency  epidemiology,  whether  water,  food,  flies, 
milk,  or  contact  be  the  original  main  route  of  infec- 
tion. The  second  step,  to  be  outlined  in  these 
pages,  is  the  location,  by  the  methods  of  concurrent 
epidemiology,  of  all  the  infected  persons  (known 
cases,  missed  cases,  and  carriers).  These  are  lo- 
cated because  each,  regardless  of  the  original  route 
by  which  he  himself  became  infected,  forms  a  new 
center  of  infection  for  spread  by  contact. 

It  was  further  pointed  out  that  neither  emergency 
epidemiology  nor  concurrent  epidemiology  were 
limited  in  their  application  to  typhoid  fever;  and 
that  the  ability  of  concurrent  epidemiology  to  handle 
properly  contact  typhoid  outbreaks,  whether  con- 
tact be  the  secondary  or  primary  route,  is  a  con- 
clusive demonstration  of  its  ability  to  handle  all 
other  infectious  diseases,  since  these  others,  while 
spread  by  public  routes  to  some  extent,  are,  in  the 

♦Emergency  epidemiology  is  the  epidemiology  re- 
quired in  outbreaks  from  single  great  routes, — water, 
food,  flies,  milk.  Concurrent  epidemiology  is  tlie  epi- 
demiology required  in  contact  outbreaks,  i.  e..  out- 
breaks from  multiple  private  sources.  Ermergency 
epidemiology  is  rapid  and  spectacular;  .  it  is  played 
hard,  against  time,  to  save  large  groups  of  people.  Con- 
current epidemiology  is  relatively  slow  and  plodding; 
it  ferrets  out,  one  by  one.  the  individual  persons  whose 
infection  threatens  families  or  small  groups.  Emer- 
gency epidemiology  will  disappear  when  the  great 
routes  are  properly  protected.  Concurrent  epidemi- 
ology will  greatly  develop;  it  is  the  most  powerful 
and  practical  weapon  yet  devised  for  the  abolition  of 
the  Infectious  diseases. 

50 


mass,  contact  infections  chiefly.  No  dependence  on 
the  argument  by  analogy  from  typhoid  fever  to 
other  diseases  is  needed,  however;  for  these  other 
diseases  are  now  and  have  been  for  years  past  han- 
dled successfully  by  these  very  methods. 

Most  persons  contemplating  the  problem  of 
finding  missed  cases  and  carriers  for  the  first 
time,  pronounce  it  impossible;  then  suggest,  as 
the  only  solution,  a  house-to-house  canvass  of 
the  whole  community,  hastily  adding  that  of 
course  such  a  measure  is  quite  impractical.  As 
a  matter  of  fact,  the  public  health  detective  does 
at  times  use,  and  use  successfully,  exactly  that 
"impractical"  measure, — the  house-to-house  can- 
vass. This  house-to-house  method  is  used  in  pri- 
mary outbreaks  from  public  routes,  to  locate  un- 
reported primary  "known  cases,"  and  also  to  lo- 
cate primary  missed  cases  and  carriers.  It  is 
necessary  in  such  primary  outbreaks  because  the 
distribution  of  primary  missed  cases  and  carriers, 
as  well  as  of  "known  cases,"  is  co-extensive  with 
that  of  the  guilty  route.  There  is  no  other  guide 
to  their  location,  and  tlierefore  the  whole  distri- 
bution of  the  guilty  route  must  be  searched.  But 
the  need  of  such  a  canvass  of  a  zvhole  community 
arises  here  only  in  typhoid  or  other  infec- 
tious intestinal  outbreaks ;  and  then  only  when 
the  infection  is  spread  by  a  route  common  to  the 
zvhole  community,  and  therefore  practically  only 
when  the  guilty  route  is  a  public  water  supply. 
In  milk  outbreaks,  those  who  did  not  use  the 
guilty  milk  heed  not  be  examined ;  and  a  similar 
statement  is  true  also  regarding  food  outbreaks. 
Fly  outbreaks  rarely  afifect  a  whole  community  un- 
less the  community  be  very  small ;  and  in  small 
communities  of  course  a  general  canvass  is  not 
difficult. 

In  the  majority  of  epidemics,  and  because  the 

51 


majority  of  epidemics  are  due,  not  to  great  pub- 
lic routes,  but  to  private  contact,  the  finding  of 
missed  cases  and  carriers  does  not  require  even 
a  partial  house-to-house  canvass.  This  is  true 
of  tvphoid,  and  other,  secondary  outbreaks 
(which  are  contact  outbreaks)  as  well  as  of  the 
great  majority  of  all  outbreaks  (since  the  ma 
joritv  are  contact  outbreaks  only. 

The  reason  why  missed  cases  and  carriers  can 
be  found  in  contact  outbreaks  without  a  house-to- 
house  canvass  depends  upon  a  fact  of  which  the 
true  significance  is  not  fully  appreciated  outside 
of  epidemiological  circles.  It  is  this  :  such  missed 
cases  and  carriers  are  not  distributed  at  pure, 
blind  random  anywhere  and  everywhere  through- 
out the  community.  They  occur  in  certain 
groups — a)id  these  groups  can  be  located  because 
they  betray  themselves  through  their  connection 
with  knozvn  cases.  Hence  the  location  of  knozun 
cases  locates  these  groups  also.* 

This  most  important  epidemiological  principle 
is  called  the  principle  of  zones  of  infection.  It 
is  the  cardinal  principle  of  concurrent  epidem- 
iology. 

The  principle  of  zotics  of  infection  was  first 
clearly  recognized  in  diphtheria  epidemics,  and 
its  development  and  demonstration  as  a  practical 
working  rule  depends,  primarily,  on  diphtheria 
investigations ;  but  both  principle  and  practice 
have  now  been  established  for  all  the  well-studied 
epidemic  diseases. 


*It  must  not  be  supposed  tuat  these  groups  are  con- 
fined to  families,  immediate  neignbors,  etc.  Their  true 
basis  is  sociological  relationship,  not  mere  pliysical 
propinquity.  In  a  single  scarlet  fever  outbreak  origi- 
nating in  one  community  Dr.  A.  J  Chesley  found  the 
related  sociological  groups  distributed  in  3  states,  in- 
volving 3  cities.  2  villages,  and  24  townships  in  10 
counties.  The  Mankato  typhoid  fever  outbreak  of  190S 
affected  over  40  points  outside  of  Maiikato. 

52 


The  epidemiologist,!  in  putting  this  principle 
into  practice,  locates  first  the  known  cases,  and 
then  searches  the  zones  of  infection,  which  they 
indicate,  for  missed  cases  and  carriers.  The  de- 
tails of  this  search  vary  with  each  disease  and 
are  too  technical  for  consideration  at  this  time. 
Detective  methods  are  used,  illuminated  bv  ex- 
pert technical  knowledge  of  each  disease,  its 
natural  history,  and  the  methods  of  recognizing 
it,  laboratory  and  clinical,  at  every  stage  and 
under  all  disguises.  Suffice  it  to  say  that  the 
finding  of  missed  cases  and  carriers,  as  well  as  of 
known  cases, — that  is,  of  the  very  framework  of 
the  ramifying  threads  of  the  infectious  disease, — 
is  a  problem  not  only  solvable,  but  already 
solved,  and  already  reduced  to  a  routine  basis. 
As  an  art,  this  concurrent  epidemiology  is  some- 
what more  arduous  and  time-consuming  than  the 
art  of  emergency  epidemiology,  but  it  is  thor- 
oughly practical  and  has  been  successfully  fol- 
lowed for  years  past  all  over  this  state,  in  an 
average  of  two  to  three  epidemics  every  week. 
The  visiting  nurse  in  ^'concurrent  epidemiology," 


tit  must  be  evident  that  those  private  practicing 
physicians  who  are  not  health  officers,  cannot,  for 
many  reasons  w^ell  understood  by  the  profession,  do 
epidemiological  work,  emergency  or  concurrent,  ex- 
cept in  overwhelming  outbreaks,  where  ordinary  con- 
ventions and  social  relations  are  temporarily  foregone. 
Even  those  private  practicing  phj^sicians  who  are  also 
health  officers,  encounter  difficulties  and  obstructions, 
ethical,  social  and  conventional,  w^hich  professional 
epidemiologists,  who  are  not  in  private  practice,  do 
not  meet.  Hence  in  all  outbreaks  the  physician  finds' 
that  his  most  valuable  functions  consist  in  treating 
the  sick  and  in  advising  protective  measures  to  those 
who  apply  to  him.  Physicians  also  often  combine, 
very  successfully,  to  publish  material  or  give  public 
lectures  of  instructions  during  epidemics.  But,  after 
all,  the  chief  service  which  the  physician  can  render 
to  official  public  health  is  the  reporting  of  known 
cases.  Known  cases,  as  has  been  show^n,  are  the  basic 
datum-points  for  emergency  epidemiology,  i.  e.,  for 
the  finding  of  the  routes  of  infection;  and  they  are 
even  still  more  important  in  concurrent  epidemiology, 
i.  e..  in  the  study  of  the  zones,  of  infection.  Epi- 
demiology is  greatly  aided  when  the  physician  per- 
forms thoroughly  this,  his  nrimary.  public  health  duty. 

53 


can  be  made  a  most  valuable  and  efficient  aid,  to 
say  nothings  at  present  of  the  other  and  even 
more  indispensable  services  in  other  directions 
which  are  within  her  especial  province. 

This  principle  of  zones  of  infection  applies  to 
tuberculosis  just  as  to  any  other  infection  spread 
by  contact ;  indeed,  the  location  of  missed  cases 
in  tuberculosis  (carriers  in  tuberculosis  are  hypo- 
thetical to  date)  offers  less  difficulty  to  modern 
epidemiology  than  the  same  problem  in  other  in- 
fectious diseases. 

FUTURE   APPLICATIONS 

So  much  for  past  and  present  practice. 

Turning  now  to  the  future  era  of  ''supervi- 
sion of  sources,"  the  principles  and  practice  al- 
ready described  pave  the  way  for  appreciation 
of  the  probable  developments.  In  reconsidering 
the  wolf  metaphor  already  outlined,  everyone 
will  ask,  and  wisely,  Why  wait  until  some  sheep 
are  killed  before  we  protect  the  others?  Why 
not  patrol  the  known  routes  by  which  the  wolves 
reach  the  sheep ;  or,  better,  build  wolf-proof 
folds ;  or,  best  of  all,  teach  the  sheep  to  protect  ir-« 
themselves — to  fight  the  wolves  or  at  least  to  -f 
dodge  them?  1 

Those  who  believe  that  infectious  disease  can  '""^ 
be  warded  off,  in  the  face  of  infection,  by  diet, '^^"'^ 

*A  most  important  exception  to  the  general  state-' 
ment  that  proper  diet  in  itself  cannot  prevent  the  def 
velopment  of  infection  provided  infection  gains  acf 
cess  to  the  body  should  be  recorded  to  cover  the  case 
of  nursing  infants.  It  lias  long  been  noted  that  breast- 
fed infants,  during  the  period  that  they  are  so  fed  (but 
during  that  period  only)  are,  practically  speaking,  im- 
mune to  many  infectious  diseases.  This  'is  so  true  of 
scarlet  fever  and  measles,  that  in  such  diseases  no 
great  concern  need  be  felt  for  such  an  infant,  even 
though  the  mother  herself  have  the  disease.  In  diph- 
theria, a  nursling  to  some  extent  shows  a  like  im- 
munity. In  smallpox,  this  is  not  true  and  in  tuber- 
culosis it  is  at  most  very  doubtful. 

That  this  escape  of  nurslings  is  purely  a  matter  of 
the   enormous   advantages   in   nutritional   value,    to   an 

54 


,  exercise,  good  ventilation,  and  "strict  observ- 
ance of  the  laws  of  bodily  health,"  are  those 
who  would  train  the  sheep  to  fight;  would  train 
the  body  to  destroy  all  infection  that  may  reach 
it.  But,  as  we  do  not  know  how  to  teach  sheep 
to  fight,  so  we  do  not  know  the  laws  of  health 

^needed  for  this  purpose  if  any  such  exist. f 
Such  methods  tested  against  infection  have  gen- 
erally failedj  so  far.  In  that  day  when  sheep 
fight  wolves  they  may  succeed.  Those  who  be- 
lieve that  the  sheep  may  be  taught  to  dodge  the 
wolves  have  much  more  in  their  favor. 

Dodging  infection  is  well  understood.  The 
physicfan,  the  nurse,  the  epidemiologist,  handle 
with  impunity  the  very  sources  of  infection 
themselves, — infected  persons  and  their  infect- 
ed discharges.  Why  not  teach  this  art  to  every 
citizen  ?  The  principle^  is  simple, — prevent  in- 
fected discharges  from  entering  the  mouth.  It 
is  in  the  practising  of  this  principle,  simple  as 

infant,  of  mother's  milk  over  other  foods  has  yet  to 
be  demonstrated.  Nursing  infants  are  by  the  mere 
fact  of  nursing"  less  likely  than  are  other  infants  to 
be  exposed  to  whatever  routes  or  sources  of  infection 
may  be  about,  unless  the  mother  is  herself  a  source. 
But  in  scarlet  fever  and  measles,  at  least,  this  is  not 
the  whole  explanation.  It  has  been  suggested  that  the 
real  reason  lies  in  the  transmission  to  the  child  of 
actual  immunity-producing  bodies  in  mother's  milk. 
If  this  be  so,  breast-feeding  in  infants  as  a  protection 
against  certain  infectious  diseases  combines  in  one 
operation  three  principles  of  defense;  good  nutri- 
tion, specific  immunization  and  the  avoidance  of  in- 
fection. Other  forms  of  feeding  fail  to  provide  these 
defences;  and  usually  combine  against  the  infant  poor 
nutrition,  absence  of  immunization,  and  exposure  to 
the  five  routes  of  infection.  Great  skill  and  care  and 
constant  watchfulness  may  serve  in  artificial  feeding 
partially  to  offset  these  dangers;  breast-feeding  auto- 
matically protects  against  them  almost  without  effort. 
Moreover,  breast-feeding  accomplishes  in  other  ■ways 
four  times  the  service  in  saving  infant's  lives  that  it 
accomplishes  in  cutting  out  infectious  diseases.  (The 
writer  "wishes  to  record  his  indebtedness  to  Dr.  J.  P. 
Sedgwick,  of  Minneapolis,  for  much  valuable  informa- 
tion on  this  subject.) 

tOnce  more  Ave  beg  our  readers  not  to  think  that 
because  building  up  the  body  cannot  make  it  proof 
against  Infectious  diseases,  building  up  the  body 
should  be  abandoned.  To  say  that  physical  care  of  the 
body  never  made  a  Newton  or  a  Shakespeare,  is  not  to 

55 


it  is,  that  the  inexperienced  person  fails.  A 
single  slip  may  be  fatal,  and  slips  are  constantly 
made.  Moreover,  to  guard  against  those  infect- 
ed persons  ivho  are  not  recognized  as  such, 
means  that  all  discharges  must  be  kept  out  of  all 
mouths  at  all  times, — a  theoretically  possible,  but, 
to  the  vast  majority  of  the  work-a-day  world,  a, 
practically  wholly  impossible,  performance.  If 
we  give  up  in  despair  the  hope  of  excluding  all 
discharges  from  all  mouths  and  attempt  to  teach 
the  ordinary  citizen  to  recognize  infection  so  that 
he  may  avoid  at  least  infected  discharges,  we 
shall  be  attempting  to  make  of  each  citizen,  man, 
woman,  and  child,  a  highly  trained  physician.  To 
teach  personal  defense  against  infection  is  a 
great  thing  for  those  who  learn  and  practice  it. 
As  a  general  method  for  abolishing  infectious 
diseases,  it  is  quite  hopeless ;  nevertheless,  each 
citizen  should  have  the  chance  to  learn  at  least 
the  principles. 

Those  who  believe  that  infectious  disease 
should  be  warded  off  by  specific  immunization 
have  some  sure  ground  to  go  upon ;  but  the 
scope  of  immunization  is  at  present  small.  These 
are  they  who  would  build  wolf-proof  folds ;  but 
we  do  not  know  how  to  build  folds  which  will 
be  proof  against  all  kinds  of  these  wolves.  It 
is  true  we  know  how  to  build  a  fold  which  is 
proof  against  smallpox,  and  that  is  vaccination. 
Also  we  are  experimenting  with  a  fold  proof 
against  typhoid,  which  is  antityphoid  inoculation. 
But,  alas,  granting  such  folds  are  built,  driving 


say  that  no  man  should  care  for  his  physical  welfare. 
The  laws  of  physical  health,  even  so  little  as  we  know 
of  them,  have  many  virtues.  Because  protection  from 
infectious  diseases  is  not  one  of  them  detracts  no  whit 
from  any  of  the  others. 

tTuberculosis  and  pneumonia  are  often  held  ex- 
ceptions to  this  rule,  but  that  they  are  exceptions  is 
being-  questioned. 

56 


the  sheep  into  them  is  a  procedure  forbidden  to 
pubHc  health,  except  in  Germany.  In  vaccination 
and  in  antityphoid  inoculation  the  old  adage  still 
applies :  "First  catch  your  sheep." 

Those  who  believe  in  guarding  routes  of  in- 
fection are  those  who  would  patrol  the  ap- 
proaches to  the  sheep.  This  is  at  least  a  pos- 
sible method,  already  established  as  of  great  val- 
ue in  some  diseases.  But  a  consideration  of  the 
following  table  shows  that,  like  immunization, 
its  scope  is  limited.  Its  scope  is  broader  than 
that  of  immunization,  but  it  is  not  broad  enough 
to  cover  all  infectious  diseases. 

If  we  tabulate  the  different  infectious  diseases 
occurring  in  the  temperate  zone  on  the  basis  of 
their  chief  routes  of  transmission  we  find  that 
water,  food,  flies,  and  milk  are  the  main  public 
routes ;  the  many  private  routes  we  group  under 
contact ;  not  every  route  operates  in  every  dis- 
ease.   Thus : 

The  Chief  Infectious  Diseases  of  the  Temperate 

Zone  Classified  by  Their  Chief  Routes 

of  Infection 

Typhoid  fever  (and  oth- 
er intestinal  infec- 
tions) are  carried 
chiefly    by water    food    flies  milk  contact 

Tuberculosis      (human)* 

is  carried  cliiefly  by flies**  milk  contact 

Diphtheria,  scarlet  fev- 
er, measles,  German 
measles,  mumps, 
w  h  o  o  p  i  n  g-c  o  u  g  h, 
smallpox,  chickenpox 
are  carried  chiefly   by milk  contact 

Syphilis,  gonorrhea, 
trachoma,  cerebro- 
spinal meningitis, 
leprosy  are  carried 
chieflj^   by    contact 

♦Bovine  tuberculosis  is  of  course  derived  chiefly  from 
the  milk  of  tuberculous  cows.  In  many  ways  this  dis- 
ease is  best  separated  for  administrative  purposes 
from  human  tuberculosis.  The  carriage  of  human 
tuberculosis  in  milk  referred  to  in  the  table  is  that 
dependent  on  the  infection  of  milk  by  tuberculous 
milk   handlers. 

**Insignificant. 

57 


Hence  water  and  food  as  great  public  routes 
of  community  infections  carry  only  the  intes- 
tinal infectious  diseases.  Flies,  practically  speak- 
ing, also  carry  this  group  only,  the  amount  of 
tuberculosis  carried  by  flies  being  small.  ]\Iilk 
carries  many  infectious  diseases,  but  contact 
alone  carries  all. 

If  we  guard  water  supplies  only  against  in- 
fection, we  eliminate  water-borne  intestinal  in- 
fections (this,  so  far  as  typhoid  is  concerned, 
would  be  about  one-third  of  the  total  typhoid  in 
Minnesota).  We  leave  untouched  intestinal  in- 
fections carried  by  food,  flies,  milk,  and  contact. 
Also  we  leave  untouched  all  other  infectious  dis- 
eases."^ If  we  guard  food,  as  w^ell  as  water,  we 
eliminate  such  intestinal  infections  as  are  car- 
ried by  food  and  water,  but  the  fly,  milk,  and 
contact  routes  for  these  remain ;  so  do  all  routes 
which  carry  the  other  infectious  diseases. 

If  we  eliminate  flies  also,  fly  typhoid  and  its 
congeners  go,  but  milk  and  contact  typhoid 
still  remain  with  us.  It  is  true  thai  a  slight  ef- 
fect on  tuberculosis  also  might  be  noted,  but 
nothing  else  is  touched.  If  we  guard  milk  sup- 
plies against  infection,?  we  begin  to  make  great 
strides,  but  contact,  the  great  route  of  human 
tuberculosis  and  of  all  the  other  infectious  dis- 
eases, including  the  intestinal  (in  ^linnesota), 
still  will  operate. 

The  fact  is  that  while  public  water,  food,  fly, 
and  milk  infections  parallel  invasion  by  wolves 
coming  from  zvithout,  contact  infection  parallels 

♦Hazen's  theorem — that  infected  water  supplies 
carry  aU  the  infectious  diseases — is  an  unproved  and 
much  disputed   hypothesis  as  yet. 

tA  great  deal  of  the  alleged  milk  supervision  of 
today  to  prevent  "watering"  or  to  keep  up  the  fat  stand- 
ard has  no  relation  -whatever  to  guarding  milk  against 
infection.  Even  the  campaign  for  clean  milk  elimi- 
nates dirt  chiefly.  Unless  especially  conducted  to  pre- 
vent infection,  it  fails  on  this  latter  score  completely. 

58 


the  presence  amongst  the  sheep  themselves,  of 
'Svolves  in  sheep's  clothing."  Such  wolves, 
because  intermingled  with  the  sheep,  cannot  pos- 
sibly be  eliminated  by  guarding  the  approaches. 
If,  then,  the  guarding  of  public  routes  can 
exclude  only  some  of  the  infection,  what  re- 
mains? 

The  extermination  of  all  the  zvolves — the 
abolition  of  the  sources  of  infection. 

If  our  modern  wolf-hunters  can  find  the  un- 
disguised wolves  and  even  the  wolves  in  sheep's 
clothing,  after  the  sheep  are  slain,  why  cannot 
they  find  them  also  before  the  sheep  are  slain? 
If  the  very  sources  of  infection  (known  cases, 
missed  cases,  and  carriers)  cannot  escape  our 
epidemiologists  armed  with  their  modern  princi- 
ples, why  wait  for  an  epidemic  before  we  go 
after  them  at  all? 

Turn  again  to  the  table  and  ♦see  that  if  we  ^ 
begin  operations  for  control  with  water,  we 
must  move  through  food  and  flies  and  milk  to 
contact  before  we  have  included  all  even  of 
typhoid ;  and  until  we  reach  contact,  we  do  not 
begin  to  touch  the  bulk  of  the  other  diseases 
at  all.  But  if  we  begin  with  control  of  con- 
tact, we  find  that  the  method  zt'hich  eliminates 
contact  infection  necessarily  eliminates  the  other 
forms  also.  That  method  when  shorn  of  non- 
essentials is  the  supervision  of  all  infectious 
persons. 

THE  NEW  PROGRAM   . 

To  drop  metaphors,  the  new  program  of  of- 
ficial public  health  is  the  abolition  of  the  in- 
fectious diseases. 

The  measures  for  this  purpose  in  progressive 
order  of  general  efiiciency,  from,  low  est  to  high- 
est,  are — 

59 


1.  The  securing  to  each  individual  citizen 
continuously  of  his  highest  possible  general 
physical  health.  Ideal  as  this  is  as  an  end  in 
itself,  it  can  have  little  effect  on  most  infectious 
diseases,  except  indirectly  during  infancy,  al- 
though it  is  supposed  to  be  a  factor  in  reducing 
tuberculosis  and  pneumonia  even  in  adults. 

2.  The  securing  to  each  individual  citizen  of 
instruction  and  training  in  the  personal  conduct 
which  he  must  follow  in  order  to  avoid  receiv- 
ing into  his  body  the  discharges  of  infected 
persons.  This  as  a  system  is  perfect,  but  the 
securing  of  the  daily  carrying  out  by  everyone 
of  the  personal  conduct  needed  is  a  hopeless 
dream. 

3.  The  securhig  to  each  individual  of  con- 
tinuous specific  immunization.  Technically  prac- 
tical as  yet  only  against  smallpox  and  typhoid 
fever  by  inoculation,  and  in  i\i fancy  against  cer- 
tain infections  %y  breast-feeding,  the  scope  of 
this  procedure  is  ve|^'  limiffed ;  and  it  must  be 
remembered  that  .the  public  have  never  yet 
adopted  even  smallpox  immunization,  except 
under  compulsion,  to  an  extent  suffKient  to  abol- 
ish even  th^  one  disease. 

These  three  measures  place  the  abolition  of  in- 
fection directly  upon  the  individual,  as  though, 
to  abolish  foot-pads,  we  should  arm  each  citi- 
zen and  train  him  in  ////  jitsii;  or  as  though, 
because  of  one  free  wolf,  we  should  put  five 
hundred  sheep  in  armor.  The  three  measures 
which  follow  place  the  abolition  of  infection  di- 
rectly upon  a  very  small  group  of  experts  who 
deal  directly  with  the  infection  itself.  These 
three  measures  would  put  the  one  wolf  in  bonds, 
and  let  the  five  hundred  sheep  go  free. 

4.  The  physical  supervision  of  the  four  great 

60 


public  routes  of  infection  (public  water  sup- 
plies, public  food  supplies,  flies,  which  are  pub- 
lic property,  and  public  milk  supplies)  to  ex- 
clude all  discharges  from  them.  The  principles 
are  well  understood,  but,  in  practice,  systematic 
application  usually  is  lacking.  (Physical  super- 
vision of  such  public  and  private  surroundings 
as,  by  their  effect  on  conduct,  may  bear  on  the 
operation  of  the  fifth  and  greatest  route  of  all, 
i.  e.,  contact,  is  necessarily  at  present  more  a 
matter  of  education  than  of  official  action,  espe- 
cially where  private  surroundings  are  involved.) 

5.  The  physical  supervision  of  all  knozvn  in- 
fectious cases  to  exclude  their  infected  dis- 
charges from  all  routes.  This,  thoroughly  done, 
would  .make  a  tremendous  impression  on  infec- 
tious diseases.  But  known  cases  form  not  more 
than  half  the  sources  of  infection. 

6.  The  sociological  supervision  of  all  infec- 
tious persons.  These  are  the  sources  of  infec- 
tious disease.  Once  found  and  supervised,  infec- 
tion from  the  human  must  stop  in  toto. 

For  the  first  three  measures,  education,  dem- 
onstration, persuasion,  are  the  things  required ; 
but  also  the  abolition  of  carelessness,  poverty, 
and  the  pressure  of  necessity.  Knowledge  alone 
is  not  enough ;  time  and  facilities  to  do  with 
are  needed  also.  Im.  supply  all  these  to  every 
citizen,  man,  wom'S'  and  child,  is  an  ideal  to 
be  sought  by  every  path ;  but  an  ideal  that  will 
take  long  years  to  realize. 

For  the  second  three  we  have  principles  and 
practice,  precedent,  authority,  some  law,  and  the 
hearty  support  of  public  opinion  in  epidemics. 
We  need  a  few  new  laws.  Chiefly  we  need 
proper   organization   and    increased   equipment  ; 

61 


but,  more  than  all,  the  hearty  support  of  public 
opinion,  continuously,  not  in  epidemics  only. 

Of  all  these  measures,  the  last  is  certainly 
the  most  inclusive ;  properly  done,  it  excludes 
the  need  (so  far  as  abolition  of  infectious  dis- 
eases is  concerned)  of  all  the  others.  It  is 
cheaper,  simpler,  easier,  more  direct  and  rapid 
than  any  other,  and  does  not  ''interfere"  with 
every  citizen,  in  every  act  of  daily  life,  indefi- 
nitely, for  it  deals  with  but  one  small  class  (in- 
fected persons),  and  only  while  infective;  and 
it  deals,  even  with  them,  merely  to  the  extent 
of  preventing  the  spread  to  others  of  their  infect- 
ed discharges. 


62 


Chapter  VI' 
INDIVIDUAL  DEFENSE 

PUBLIC  DEFENSE  AND  PRIVATE 

The  preceding  chapter  distinguished  sharply 
those  things  necessary  to  escape  disease,  which 
individuals  may  do,  from  those  things  necessary 
to  prevent  disease,  which  communities  must  do, 
because  individuals  cannot. 

/J"he  present  chapter  will  outline  the  former. 
As  already  indicated,  these  individual  efforts 
may  be  made  in  three  directions : 

^1.     To  secure  high  general  physical  health. 

^2.  To  secure  sprecific  immunity  to  specific 
diseases. 

;3.  To  avoid  disease,  especially  infectious  dis- 
ease. 

Efforts  in  the  first  direction  would  aim  to  build 
up  and  make  palaces  of  the  bodies  in  which  we 
dwell  and  which,  too  often,  are  mere  hovels ;  but, 
alas,  the  palace  burns  as  easily  as  the  hovel.  It 
•would  be  futile  to  seek  the  physical  advancement 
of  the  race  in  order  to  abolish  disease.  We  should 
seek  the  abolition  of  disease  in  order  to  physically 
advance  the  race. 

THE  PREVJ^NTABILITY  OF  THE  '^PREVENTABLE'' 
DISEASES 

True,  we  should  not  await  this  abolition  be- 
fore seeking  general  physical  advancement,  but, 
unfortunately,  we  know  as  yet  few  practicable 
rules  of  general  application,  except  for  infants, 
to  achieve  such  physical  advancement.     Far  bet- 

63 


ter  than  how  to  secure  high  physical  health  we 
know  how  to  avoid  disease,  at  least,  how  to  avoid 
certain  diseases.  A  few  of  these  are  non-infec- 
tious environmental  diseases,  like  scurvy  and 
miner's  elbow  ;  and  the  non-infectious  poisonings, 
like  the  poisonings  from  lead,  arsenic,  phos- 
phorus, alcohol,  and  illuminating  gas.  These  dis- 
eases depend  upon  readily  recognized  mechanical 
or  physical  surroundings.  A  change  of  diet  in 
scurvy  or  of  position  in  miner's  elbow ;  stopping 
leaks  in  pipes  for  illuminating  gas  poisoning ;  re- 
fusal to  admit  the  other  poisons  to  the  body — • 
and  all  are  abolished.  These  non-infectious 
poisons  furnish  but  l^.m  1,000  of  all  deaths, 
except  in  infancy,  where  non-infectious  intestinal 
poisonings  furnish  a  large  proportion. 

On  the  other  hand,  the  poisonings  which  are 
infectious,  i,  e.,  the  infectious  diseases,  furnish 
more  than  one-sixth_  of  all  the  deaths,  and  about 
one-half  of  these  deaths  are  from  one  infectious 
disease,  namely,  consumption.  Like  the  chemical 
poisonings, — lead,  arsenic,  etc., — the  infectious 
diseases  depend  on  noxious  materials  that  enter 
the  body.  But,  unlike  lead,  arsenic,  etc.,  the 
poisons  which  produce  the  infectious  diseases 
are  associated,  not  with  a  few  well-known  ma- 
terial surroundius^s  and  inanimate  things,  but 
with  the  living  activities  of  many,  often  unknown, 
persojis. 

The  little  we  know  of  how  to  achieve  high 
health,  and  the.  much  more  we  know  of  how  to 
avoid  disease,  should  be  taught  our  2,000,000 
citizens  of  Mii^nesota.  This  huge  task  requires 
a  mechanism  so  huge  that  onlv  our  huge  public 
school  system  can  accomplish  it.* 


*It  is  often  said  that  practising-  physicians  should 
teach  health  to  the  public.  In  one  sense  this  is  true. 
Physicians     represent     medicine,     and     medicine     deals 

64 


Efforts  in  the  second  direction  (for  specific  im- 
munization) would  aim  to  "fireproof"  our  bodies 
against  disease,  whether  those  bodies  be  "pal-" 
aces"  or  "hovels."  But  such  fireproofing  can  as 
yet  be  done  only  against  smallpox  and  typhoid 
fever.** 

Also,  just  as  the  general  public  will  not  fire- 
proof literal  houses  against  literal  fire,  despite 
large  fire  losses  every  year,  so  the  general  public 
[^will  not  fireproof  their  bodies  against  infection, 
even  against  smallpox.  One  hundred  years  ,  of 
vaccination  has  left  us  in  Minnesota  with  only 
30  per  cent  of  children  under  16  years  of  age 
protected  against  smallpox.  We  shall  be  lucky 
if  10  years  of  antityphoid  inoculation  finds  us 
with  10  per  cent  of  adults  protected  against  ty- 
phoid, i  In  the  absence  of  compulsory  laws,  rig- 
orously enforced,  immunization  must  remain  a 
task  of  systematic  education,  reaching  everyone, 
and  this  task  also  only  the  public  school  system 
can  properly  perform. 

^  Efforts  in  the  third  direction  would  aim  to  shut 
out  all  poisons,  including  all  infections^  from 
all  bodies,  whether  these  bodies  be  palaces  or 
hovels,  on  the  principle  that  as  no  dwelling,  pal- 

with  disease,  its  cure,  and  its  prevention.  But  prac- 
tising engineers  might  as  weU  be  drafted  to  teach 
geometry  as  practising  physicians  to  teach  personal 
hygiene.  Physicians  dealing  with  their  own  patients, 
or  even  lecturing  or  writing  on  these  subjects,  do 
much  good.  Such  work,  however,  is  but  a  drop  in 
tiie  bucket,  reaching  only  a  fraction  of  the  public  and 
generally  just  that  fraction  which  needs  it  least. 
There  are  over  2,000  practising  physicians  in  Minne- 
sota. They  have  not  time,  training,  organization,  or 
authority  for  the  sort  of  teaching  that  will  really 
reach  all  citizens;  the  public  school  system  has  all 
four,   and  15,000  teachers  to   do  it  with. 

Medicine  must  furnish  the  facts  that  are  to  be 
taught,  but  it  is  quite  impossible  that  practising  phy- 
sicians should  do   the  teaching. 

**The  immunity  possible  against  diphtheria  through 
protective  doses  of  diphtheria  antitoxin,  is  too  short- 
lived for  general  continuous  application  to  all  citi- 
zens. 

G5 


ace,  or  hovel  can  burn  if  fire  do  not  reach  it,  so 
our  bodies,  good,  bad,  or  indifferent,  cannot  be 
destroyed  by  disease  if  the  causes  of  disease  be 
shut  out  from  them.  To  aboHsh  literal  fire  from 
literal  dwellings  is  impracticable,  for  fire  is  too 
useful  for  abolition.  Disease  serves  no  useful 
purpose,  and  its  abolition  is  the  only  reasonable 
goal. 

^The  exclusion  of  the  poisons  of  disease,  in- 
fectious or  non-infectious,  from  the  body,  is  the 
most  successful  preventive  measure  we  have 
at  present  against  most  diseases  that  are  prevent- 
able at  all.  The  methods  should  be  taught  to 
every  citizen ;  and  for  this  again  th^public  school 
system  alone  is  able.  Public  health  experts  must 
supply  the  facts ;  it  is  quite  impossible  that  they 
should  do  the  teaching."^ 

''dodging  infection'' 

Dodging  infection  rests  on  simple  principles, 
already  outlined.  The  one  essential  is  to  exclude 
from  entrance  to  the  body,  matter  from  infec- 
tious bodies  ;  i.  e.,  in  briefest  practical  form,  for 
all  except  the  venereal  diseases,  to  ^exclude  from 
the  moHfli  the  infected  discharges  of  others. 
\^o  do  this  requires,  first,  the  ability  to  recog- 

*Of  each  1,000  school  children  in  Minnesota  schools, 
450  leave  school  at  the  end  of  the  6th  grade  work,  450 
leave  at  the  end  of  the  8th  g-rade.  The  remaining-  100 
enter  the  high  school;  but  only  50  graduate.  Ten  out 
of  the  1.000  thousand  enter  the  University;  5  gradu- 
ate. We  now  teach  in  the  earlier  grades  theoretical 
anatomy  and  theoretical  physiology,  intending-  thus 
to  form  foundations  for  later  practical  information. 
Since  90  percent  of  children  leave  at  the  8th  grade, 
this  90  percent  receive  the  theoretical  information 
only;   they  never  learn   its  practical   use  at  all. 

This  system  needs  inversion.  We  should  teach  the 
practical  parts  of  hygiene  and  of  avoidance  of 
disease  to  the  100  percent  of  children;  i.  e.,  not  later 
than  the  6th  grade,  leaving  the  theoretical  parts  for 
the   10   percent  that  take   the   higher  courses. 

The  State  Superintendent  of  Education,  Mr.  C  G. 
Schulz,  authorizes  the  statement  that  he  is  making 
plans  to  have  these  subjects  taught  in  the  public 
schools  in  the  manner  indicated,  just  as  soon  as  ar- 
rangements can  be  made. 

66 


iiize  infectious  persons ;  and,  second,  the  skill 
to  avoid  their  discharges. .  But  we  cannot  teach 
the  general  public,  half  of  them  children,  to  rec- 
ognize infectious  persons.  If,  then,  we  broaden 
the  rule  and  teach  avoidance  of  discharges  of 
all  sick  persons,  whether  infectious  or  not,  we 
ignore  those  persons  who  are  infectious  without 
being  sick.  Hence,  for  the  non-medical  citizen, 
the  rule  must  run :  Exclude  all  discharges  of  all 
persons  from  all  mouths.  But  this  is  by  no  means 
so  easy  as  it  sounds. 

""contact""" 

Mouth-discharges  are  exchanged  in  the  form 
of  mouth-spray,  sputum,  and  smears  on  various 
things,  but  chiefly  by  smears  on  hands. 

Mouth-spray  consists  of  tiny,  often  micro- 
scopic, drops  of  liquid  from  the  mouth,  thrown 
out  in  sneezing,  coughing,  shouting,  singing,  and 
speaking,  but  not  in  quiet  breathing.  The  larger 
ones  can  be  seen,  if  watched  for,  and  they  can 
be  felt  falling  upon  the  face  in  face-to-face  con- 
versations. Talk,  or  sing,  or  shout,  or  cough,  or 
sneeze  against  a  mirror  two  feet  distant,  and 
count  the  drops  that  strike  it.  Then  picture  to 
yourself  what  happens  at  ''teas"  and  ''sociables" ; 
at  meals,  with  lively  conversation  going  on ;  at 
school;  at  church.  Think  also  of  what  happens 
when  the  cooks  or  waiters  talk  while  preparing 
food,  cough  while  laying  tables,  or  sneeze  while 
wiping  dishes. 

This  distribution  of  mouth-spray  cannot  be 
prevented  unless  all  wear  masks,  as  modern  sur- 
geons do  when  opTerating. 

But  exchange  of  mouth-spray  may  be  avoided 
somewhat  by  avoiding  close  face-to-face  conver- 
sations, as  by  sittinq-  side  by  side  or  far  apart; 
by  coughing  or  sneezing  always  into  a  handker- 

67 


chief,  etc.  Often,  of  course,  the  cough  or  sneeze 
comes  too  quickly  or  the  hands  are  already  full. 
It  is  true  that  the  head  may  be  turned  aside ;  but 
often  this  spares  the  person  in  front  at  th^  ex- 
pense of  others,  and,  while  coughing  or  sneezing 
into  the  hand  prevents  the  mouth-spray  from 
flying  wide,  the  spray  goes  to  the  hand  and  the 
hand  itself  passes  it  on  to  the  other  persons  later. 

There  is  no  practical  method  of  avoiding  all 
mouth-spray  of  associates,  except  not  to  have 
associates ;  but  the  amount  of  exchange  may  be 
diminished  by  the  above  precautions. 

Sputum,  through  the  spitting  habit,  falls  upon 
floors,  steps,  sidewalks.  That  these  deposits  dry 
and  blow  about  as  dust  is  the  least  of  the  dan- 
gers, especially  out  of  doors,  for  sunlight  and  dry- 
ing disable  most  disease  germs.  Sputum  follows 
a  much  more  important  route  leading  to  mouths, 
and  this  route  is  followed,  not  when  the  sputum 
has  become  dry  and  dusty,  but  while  it  is  still 
fresh  and  moist, — while  the  germs  in  it  are  still 
alive.  This  route  is  by  way  of  shoes,  directly 
into  houses.  There,  wiped  off  on  carpets,  it 
awaits  the  creeping  baby;  it  smears  itself  on  the 
baby's  fingers ;  and  he  carries  it  directly  into  his 
mouth.  Also,  in  removing  shoes,  the  owner  of 
the  shoes  uses  his  fingers  and  then,  too  often, 
the  owner's  fingers,  just  like  the  baby's,  enter 
the  mouth  unwashed.  The  value  of  anti-spitting 
ordinances  thus  becomes  apparent. 

But,  after  all,  hands  are  the  great  route  of 
exchange,  and  hands  furnish  the  great  route  for 
bladder  and  bowel  discharges,  as  w^ell  as  for  nose 
and  mouth.* 


*Hancls  do  not  carry  only  infectious  diseases.  They 
are  the  chief  routes  by  which  lead  is  carried  to 
mouths  in  lead-poisoning,  and  a^re  also  an  important 
factor  in  phosphorus  poisoning. 

68 


From  birth  to  death  those  universal  tools,  our 
hands,  g^o  to  our  mouths  incessantly ;  from  birth 
to  death  we  use  them  for  every  other  purpose 
also.  Hands  encounter  all  the  discharges  of  the 
body  many  times  a  day;  and  if  not  scrupulously 
washed  on  every  such  occasion,  they  carry  these 
discharges  to  everything  they  touch,  including 
other  hands,  which  go  to  other  mouths.  The 
very  handkerchiefs  we  advocate  to  cough  or 
sneeze  or  blow  our  noses  into,  transfer  these 
same  discharges  to  our  fingers,  the  next  time  that 
we  use  them.'^'''^ 

Then  we  shake  hands  with  others,  or  feel  the 
baby's  new  tooth.  Visits  to  toilets,  unless  fol- 
lowed at  once  by  careful  hand-washing,  mean 
similar  transfer  of  the  toilet  discharges  as  well, 
particularly  amongst  children,  who,  remember, 
form  half  the  population. 

The  common  drinking-cup  and  the  common 
drinking-pail  are  bad  because  they  help  to  ex- 
change mouth-discharges ;  the  roller-towel  is 
worse,  especially  when  used  for  half-zvashed 
hands,  because  then  it  helps  to  exchange  all  the 
bodily  discharges :  but  the  unzvashed  hands  them- 
selves are  worst  of  all,  because  the  discharges 
they  carry  are  undiluted  and  fresh  and  moist  and 
warm.  When  strangers  enter  a  household,  they 
add,  through  mouth-spray  and  hands,  their  dis- 
charges to  the  general  household  stock ;  and, 
due  to  this,  harvesting  help,  threshing  crews,  etc., 
introduce  infectious  disease  into  numerous  rural 
families  and  communities  every  year. 

Within  the  purview  of  the  private  citizen  at 
home,  discharges  are  also  exchanged  somewhat 
through  things  soiled  by  mouth-spray  and  hands, 

*It  has  been  suggested  that  the  left  hand  should  be 
used  for  handkerchiefs,  thus  leaving-  the  right  hand 
clean  so  far  as  these  discharges  are  concerned. 

69 


as  well  as  directly.  Thus  are  contaminated  dishes 
in  laying  the  table,  bread,  cake,  etc.,  also  pillow- 
cases and  sheets  which  are  soiled  by  mouth  or 
other  discharges  from  the  body.  The  list  of 
the  things  which  may  carry  such  discharges,  is 
too  long  for  itemizing  here ;  but,  in  general,  such 
things  do  not  form  really  very  important  routes 
of  transfer,  except  when  the  discharges  are  con- 
siderable in  quantity  and  while  the  discharges  are 
fresh  and  moist.  Once  dried  on  clothing,  mouth- 
spray,  for  instance,  is  not  readily  set  free,  and 
when  it  is  dry,  infection,  if  present,  dies  out  with 
fair  rapidity.  Just  as  the  main  public  routes  of 
discharges  from  the  community  to  the  family  are 
public  water  supplies,  public  food  supplies,  public 
milk  supplies,  and  public  outdoor^  flies,  so  the 
main  private  routes  within  the  family,  apart  from 
mouth-spray,  sputum,  and  hands,  are  private 
water  supplies,  private  food  supplies,  private  milk 
supplies,  and  private  indoor  flies.  Public  sup- 
plies may  or  may  not  bring  discharges  with  them 
to  the  family ;  once  they  enter  the  family,  they 
pretty  surely  receive  them  from  the  family  itself. 
So  also  with  the  private  supplies  of  the  same 
things :  the  family  well  may  or  may  not  be  dosed 
with  the  family  discharges ;  the  family  drinking- 
pail  or  pitcher  almost  always  is ;  the  family  cow 
may  or  may  not  contribute  discharges  to  the  fam- 
ily milk-pail,  but  the  family  milker  practically 
always  does*  ;  and  latej:,  within  the  family,  the 
family  milk-pitcher  receives  the  family  mouth- 
spray.  The  family  food,J^'fore  and  even  after 
cooking,  is  subject  tCsimilar  contamination.  The 
family  flies  moving  from  the  "outdoor  toilet,  un- 

*If  a  milker  talks  or  singrs  or  cous"hs  or  sneezes, 
using  a  ^vicle  mouth  pail,  his  mouth  discharges  enter 
the  milk.  If  he  milks  with  unwashed  hands,  all  his 
discharges   enter   the   milk    also. 

70 


less  it  be  fly-proof,  or  from  indoor  spittoons  or 
slops  to  food,  aid  in  the  same  exchange.* 

Knowing  these  dangers  is  half  the  battle  won. 
Against  infection  of  public  routes, — public  water 
supplies,  public  food  supplies,  public  outdoor 
flies,  and  public  milk  supplies, — the  private  cit- 
izen should  not  need  precautions,  for  these  the 
community  itself  should  guard.  But  if  he  need 
them,  the  private  citizen  has  against  such  public 
routes  two  powerful  weapons:  (a)  exclusion 
from  his  premises  of  the  infected  route,  and  (b) 
cooking.  Foods  are,  of  course,  usually  cooked, 
even  in  ordinary  life ;  water  may  be  boiled,  milk 
Pasteurized,  and  if  flies  cannot  be  excluded,  the 
food  they  contaminate  can  be  rejected  or  cooked 
again. 

The  public  routes  of  infection  are  not  difficult 
for  the  citizen  to  guard  against,  however  onerous 
that  guarding  may  be :  the  real  difficulty  is  with 
the  private  routes,  the  routes  of  contact  that 
carry  infection  within  the  family  and  also  within 

the  school,  the  office,  the  workshop,  the  factory. 
We,  individually  or  collectively,  may  abolish  in 
time    the    common    drinking-cup    and    common 

*A  curious  perversity  of  human  nature  makes  us 
attach  undue  importance  to  many  possible  but  unim- 
portant routes  of  discharges,  like  telephone-receivers, 
dirty  money,  the  licking-  of  postage  stamps,  etc.,  while 
we  neglect  the  commonplace,  really  important  routes, 
acting   daily   and   everywhere,    above    outlined. 

An  example  of  the  same  thing  is  seen  in  the  great 
anxiety  expressed  concerning  meat  as  a  route  of  in- 
fection. It  seems  to  be  remembered  but  seldom  that 
meat  is  almost  always  cooked;  i.  e.,  it  almost  always 
automatically  receives  the  very  treatment  w^e  solicit- 
ously prescribe  for  blocking  infection  through  milk 
and  thro.ugh  water.  Meat-inspection  is  wholly  proper, 
to  secure  good"  meat,  and  to  prevent  the  robbing  of 
the  consumer's  pocket  and  the  consumer's  stomach. 
But  all  the  meat-inspection  in  the  world  could  not 
reduce  our  ordinary  infectious  diseases  by  one-tenth 
of  1  percent.  Meat,  as  food,  especially  cold  meat,  often 
carries  the  family  discharges,  but  disease  in,  or  dis- 
charges attached  to,  meat  from  its  sources  outside  the 
family,  are  in  most  cases  destroyed  by  cooking. 

71 


roller-towel,  but  no  one  can  ever  abolish  mouth- 
spray  or  hands.* 

It  is  true  that  by  education'"'''^'  we  may  greatly 
affect  personal  conduct,  but  to  leave  the  abolition 
of  infection  in  ordinary  life  to  the  personal  con- 
duct of  all  sorts  of  people,  half  of  them  children, 
would  be  as  wise  as  to  trust  the  destruction  of 
infection  in  a  water-borne  typhoid  outbreak  to 
the  boiling  of  the  water  by  the  private  citizens. 

♦Two  minion  mouths,  served  by  4,000,000  hands, 
receive  6.000,000  meals  in  Minnesota  daily.  But  this 
is  not  as  important  as  are  the  hands  that  handle  the 
meals  in  preparation;  moreover,  hands  go  to  mouths 
far  more  often  between  meals  than  during  them. 

**The  follow^ing  rules  prepared  for  use  in  the  public 
schools  at  the  request  of  County  Superintendent  Geo. 
S.  Selke,  Benton  County,  indicate  the  main  points  to 
be  taught  concerning  protection  froin  infectious  dis- 
eases in  the  schools.  They  indicate  also  pretty  closely 
what  can  be  done  in  the  home  and  for  this  reason  they 
are   inserted  here. 

Placard  for  Schools 

The  germs  of  infectious  diseases  are  in  the  dis- 
charges of  infectious  persons.  Infectious  diseases  are 
"caught"  from  infectious  persons  simply  by  taking 
into  the  mouth  some  portion,  usually  very  small,  of 
their   infected   discharges. 

The    Great    Rules    of    Prevention    in    School.s. 

1.  Exclude  from  school  all  infectious  persons,  thus 
excluding   all   infectious   discharges. 

2.  Since  infectious  persons  may  enter  school  at 
times  despite  the  greatest  vigilance,  restrict,  so  far 
as  possible,  the  scattering  of  any  discharge  of  any 
person  at  any  time  in  school.  (This  will  also  train 
the  children  to  restrict  their  discharges  out  of  school 
and  in  after-life). 

a.  Mouth  discharges  are  transferred  directly  to 
and  taken  directly  from  drinking-cups,  towels,  pencils, 
chewing-gum,  whistles,  etc.  Mouth,  nose,  bladder,  and 
bowel  discharges  are  transferred  directly  to  hands 
many  times  daily.  Hands  go  to  mouths  many  times 
daily;    therefore — 

Provide  individual  drinking-cups.  individual  towels, 
individual  pencils,  individual  modeling-clay,  individual 
modeling-sand,  etc.  There  shoiild  be  a  sign  in  every 
school.  "Wash  your  hands  after  every  visit  to  a  toilet." 

b.  Sputum  (spit)  or  other  discharges,  deposited  on 
floors,  sidewalks,  etc.,  are  picked  up  by  shoes  and  so 
carried  into  homes.  When  handling  shoes  (putting 
on,  taking  off,  etc.).  discharges  are  transferred  to 
hands,  which  go  to  mouths,  or  touch  things  that  go 
to   mouths.     Therefore — 

Avoid  depositing  discharges.  —  sputum,  etc.,  —  on 
floors,  sidewalks,  or  elsewhere  where  other  people  may 
step  on  them. 

c.  Mouth-spray  is  thrown  out  in  talking,  singing, 
coughing,  sneezing,  etc.,   therefore — 


Avoid  throwing-  mouth-spray  into  other  people's 
faces  by  avoiding-  close  face-to-face  conversations, 
face-to-face  recitations,  face-to-face  singing-exercises, 
etc.      Cough,    sneeze,    etc.,    into   a   handkercliief  always. 

d.  The  air  of  a  schoolroom  in  use  necessarily  re- 
ceives  mouth-spray   into   it   in   talking,   reciting,   etc. 

e.  Bladder  and  bowel  discharges  are  carried  by 
flies  when  flies  can  get  at  them.  During  early  autumn 
and  late  spring  or  summer  sessions,  flies  may  carry 
these  discharges  from  toilets  to  children's  lunches, 
etc.,    therefore  — 

Make  toilet-vaults  fly-proof.  Provide  springs  or 
weights  to  automatically  close  toilet-doors,  and  fly- 
screens   for   toilet-windows. 

f.  Three  things  destroy  comfort  and  success  in 
school  work:  Temperature  too  high;  atmosphere  too 
dry;  air  not  in  motion.  Also,  no  child  can  work  well 
in  a  poorly  lighted  room;  but  do  not  imagine  that 
good  lighting,  good  heating,  and  good  ventilation  will 
prevent  spread  of  infection  if  infectious  persons  gain 
entrance.  No  school  is  a  sanitary  school  if  the  chil- 
dren exchange  their  discharges  without  restriction; 
but  only  those  schools  "where  infectious  persons  are 
watched  for  and  excluded  are  safe  schools.,  therefore — 

Note  daily  the  general  state  of  health  of  each  child. 
No  child  who  shows  any  decided  change  from  the  usual 
for  that  child,  especially  fever,  h&adache,  sore  throat, 
stomach-ache,  or  general  dumpishness,  should  attend 
school  until  seen  by  a  physician.  This  rule  permits 
early  detection  of  infectious  children.  It  also  excludes 
children  who  should  be  excluded  for  their  own  good, 
even  if  non-infectious. 

g.  Children  showing  defective  vision,  hearing, 
breathing,  etc.,  should  be  referred  to  the  principal, 
superintendent,    or   school  board   for  action. 

All  health  officers  know  that  adults  in  large  pro- 
portion zi'ill  not,  and  children  cannot,  boil  the 
water.  Moreover,  the  law  in  Minnesota  now 
recognizes  that  the  community  has  no  right  to 
supply  water  of  such  a  kind  that  the  consumer 
must  protect  himself  against  it.  This  principle 
should  be  extended,  so  that  the  community  is 
held  responsible  for  infection  carried  by  any 
public  route, — food,  milk,  or  flies, — as  well  as  by 
public  water.  Some  day  the  equally  logical  step 
should  follow, — the  holding  of  the  community  re- 
sponsible for  all  infectious  diseases,  by  zvhatever 
routes  they  travel,  including  contact.  The  com- 
munity, thanks  to  modern  science,  can  abolish 
the  sources  of  all  infectious  diseases ;  and  once 
the  sources  are  abolished,  the  diseases,  being  non- 


existent,   cannot  travel   b}-   any   route,   even   by 
contact. 

The  simple  fact  is,  that  the  private  citizen  in 
his  own  home  can  protect  himself  against  public 
routes  of  discharges  as  just  outlined  and  from 
the  family  discharges  to  some  extent ;  but  the 
moment  he  leaves  home  and  enters  into  relations 
with  the  general  public,  his  individual  control  is 
at  an  end.  He  cannot  guard,  generally  he  can- 
not even  ascertain,  the  sources  or  routes  of  the 
water,  milk,  food,  or  flies  he  must  encounter. 
Above  all,  he  cannot  guard  the  sources  or  routes 
of  the  discharges  furnished  by  the  persons  he 
necessarily  meets.  His  children  go  to  school, 
compelled  directly  by  the  law  to  do  so,  and 
there  they  share  discharges  which  no  personal 
defense  through  conduct  can  wholly  avoid.  He 
goes  himself  to  work,  compelled  indirectly  by 
the  law  to  do  so,  and  there  he  shares  discharges 
which  he  can  little  or  not  at  all  control.  Only 
the  community  can  exclude  infection  from  the 
public  routes  of  discharges,  water,  milk,  food, 
and  flies ;  but  also  only  the  community  can  ex- 
clude infection  from  the  private  routes  of  dis- 
charges grouped  under  ''contact." 

Of  course,  the  exchange  of  discharges  already 
outlined,  however  inevitable,  is  harmless  unless 
and  until  infected  discharges  enter  into  the  ex- 
change. The  chances  of  encountering  infected 
discharges  can  be  approximated  somewhat  from 
the  supposition  that  daily  there  goes  at  large, 
unknown,  about  one  infective  person  in  each  500 
of  the  population.  Hence,  he  who  would  de- 
fend himself  from  infection  by  his  habitual  per- 
sonal conduct  toward  his  associates  must  avoid* 
the  harmless  discharges  of  499  uninfected  per- 
sons in  order  to  avoid  the  harmful  discharges 

■  '\ 


r 


of  one  unknown  infected  person.  (This  estimate 
is  necessarily  a  guess,  and  it  does  not  include  the 
venereal  infections.) 

The  great  weakness  of  the  personal  defense 
through  conduct  is  this :  The  precise  moment 
when  it  is  most  needed  is  the  precise  moment 
that  it  generally  fails.  In  the  first  place,  the 
mouth-spray  of  the  ordinary  well  person  is  not 
half  so  abundant  or  so  widely  scattered  as  that 
of  the  case  of  tuberculosis,  of  measles,  of  whoop- 
ing-cough, or  of  influenza,  for  these  are  just  the 
diseases  in  which  coughing  and  sneezing  are 
prominent  symptoms.  The  bowel-discharges  of 
the  ordinary  well  person  are  not  half  as  likely  to 
be  disseminated  as  those  of  the  typhoid  or  dysen- 
tery case,  for  these  are  just  the  diseases  in  which 
frequent,  abundant  liquid  stools,  often  involun- 
tary, occur.  Again,  the  discharges  of  the  well 
person  are  handled  chiefly  by  that  well  person 
himself :  the  discharges  of  the  sick  must  often  be 
handled  by  associates  unused  to  performing  such 
services  for  others.  Finally,  exactly  as  green 
troops  forget  under  fire  all  their  parade-ground 
drill,  trip  over  their  own  feet,  and  fire  into  the 
ground  or  at  the  sun,  so  the  citizen,  however 
carefully  he  may  have  practiced  a  well-thought- 
out  system  of  avoiding  discharges  in  ordinary 
life,  goes  all  to  pieces  in  the  flurry  when  his 
child  develops,  say,  scarlet  fever.  Of  course, 
it  is  true  that  green  troops  soon  recover  their 
parade-ground  drill,  even  in  the  face  of  the  en- 
emy ;  but  they  cannot  do  what  seasoned  troops 
can  do,  and  the  non-medical  citizen  can  seldom 
protect  himself  in  the  face  of  infection  as  the 
trained  contagious-disease  nurse  does,  the  physi- 
cian, or  the  epidemiologist.  Nevertheless,  if  he 
has  previously  known,  and  practiced  even  crude- 

75 


ly,  the  necessary  precautions,*  he  is  in  a  much 
better  position  to  defend  himself. 

SUMMARY 

The  whole  subject  of  public  health  divides 
itself  into — 

1.  Securing  high  physical  development  and 
efficiency. 

2.  Avoiding  disease. 

Of  the  former  we  know  little  of  practical  ap- 
plication to  the  general  population  except  in  in- 
fancy. 

Of  the  latter  we  know  much  of  cure,  but  lit- 
tle of  prevention,  except  in  the  environmental 
diseases,  in  the  poisonings,  as  from  lead,  arsenic, 
alcohol,  etc.,  and  especially  in  the  infectious  dis- 
eases. 

Defense  against  environmental  diseases  and 
the  non-infectious  poisonings  is  largely  a  matter 
of  trade  conditions  and  of  avoiding  dangerous, 
but  known,  non-living  things  and  therefore 
largely  of  legislation,  inspection,  and  conduct. 
Against  infectious  diseases,  the  sources  being 
infected  persons,  defense  is  essentially  a  matter 
of  precautions  against  those  persons.  The  prime 
difficulty  is  the  recognition  of  those  persons.  If 
they  are  not  recognized,  the  defense  becomes  a 
matter  of  guarding  against  all  persons. 

Defense  against  infection  may  be  divided  into 
individual  and  community  defense. 

*It  is  a  fatal  faUacy  to  believe  in  "general  cleanli- 
ness" as  a  defense  against  infection.  It  is  not  the 
"general  cleanliness"  of  surroundings  that  prevents 
infectious  diseases;  it  is  the  "specific  cleanliness"  of 
freedom  from  infected  discharges.  Scrubbed  floors, 
bright  pans,  neatness,  and  order  do  not  necessarily  in- 
volve, usually  do  not  imply,  hands  free  of  discharges; 
they  cannot  stop  mouth-spray.  A  gorgeous  uniform 
no  more  shows  ability  to  shoot  than  does  "general 
cleanliness"  show  ability  to  avoid  infection.  It  is  not 
visible  dirt  that  hurts. — mud,  ashes,  coal-dust, — but 
the  usually  invisible  discharges  in  mouth-spray  and 
on  hands,  and  even  these  only  when  laden  with  infec- 
tion. 

76 


Infectious  diseases  are  carried  by  four  main 
public  routes — water,  food,  flies,  and  milk,  and  by 
a  fifth  private  route,  contact.  By  cooking  all  ali- 
mentary supplies  before  eating-  them,  the  public 
routes  may  be  guarded  at  the  consumer's  end, 
but  public  opinion  and,  in  the  matter  of  water 
supplies,  the  law,  rightly  demand  the  transfer  of 
this  burden  of  protection  to  the  producer. 

The  private  routes  of  contact  can  be  guarded 
by  the  individual  also,  but  only  by  a  ritual  so 
elaborate  and  covering  so  general  a  field  that  it 
does  not  adequately  meet  the  ordinary  conditions 
of  the  ordinary  life  of  the  ordinary  citizen,  espe- 
cially of  hard-working  fathers,  hard-driven  moth- 
ers and  young  children.  Contagious-disease  ex- 
perts, with  long,  patient  training  and  when  deal- 
ing with  known  infected  individuals,  generally 
succeed ;  the  ordinary  untrained  citizen  must  very 
often  fail. 

Notwithstanding  that  the  community  can  and 
should  assume  the  prevention  of  contact-infection 
(by  excluding  infection  from  the  community  en- 
tirely), as  well  as  the  care  of  the  four  public 
routes,  the  methods  of  personal  defense  should 
be  well  known  to  all ;  and  there  exists  no  means 
of  teaching  them  comparable  at  all  with  the  great 
public  school  system,  for  that,  and  that  alone, 
reaches  the  citizens  personally  and  in  detail. 
There,  in  simple  language,  all  that  is  useful  can 
be  readily  taught,  and  it  must  be  taught  in  the 
sixth  grade,  or  earlier,  to  reach  the  population  as 
a  whole. 


77 


Chapter  VII 
COMMUNITY  DEFENSE 

THE   PUBLIC    HEALTH    ENGINEER 

The  prepe^ing  chapter  indicated  the  Hnes  of 
personal  defense  against  infectious  disease  which 
are  avaitable  to  the  private  citizen  for  his  own 
protection  through  his  own  efforts. 

The  present  and  succeeding  chapters  will  deal 
with  community  defense,  —  those  operations 
which,  if  properly  conducted  by  communities  for 
the  good  of  all,  would  make  unnecessary  the 
burdensome  efforts  of  individuals  to  protect 
themselves. 

The  three  great  community  measures  for  the 
abolition  of  infectious  disease  have  been  listed 
in  increasing  order  of  efficiency  as — 

1.  The  protection  of  all  public  routes  of  in- 
fection, public  water  supplies,  public  food  sup- 
plies, public  milk  supplies,  and  public  flies.  This 
is  now  done  in  some  places  to  some  extent.  Usu- 
ally it  is  but  half  done,  chiefly  for  lack  of  proper 
understanding  of  what  are  real  protective  meas- 
ures, or  of  proper  organization  for  their  exe- 
cution ;  too  often,  also  for  lack  of  proper  men 
to  carry  them  out. 

2.  The  physical  supervision  of  known  cases 
of  infectious  diseases.  This  also  is  often  now 
attempted.  Indeed  it  is,  on  paper,  the  most  de- 
veloped of  all.    But  its  efficiency  is  cut  down  by 

78 


lack  of  reporting,  concealing  of  cases  from  phy- 
sicians, etc.,  and  especially  by  lack  of  sufficient 
trained  experts  in  epidemiology  to  do  the  close- 
to-the-ground  daily  work. 

3.  The  sociological  supervision  of  all  infec- 
tious persons,  already  outlined  in  previous 
articles. 

The  first  of  these  items  is  dealt  with  here. 

For  the  protection  of  the  public  routes  of  in- 
fection three  things  are  needed :  proper  physical 
construction,  to  exclude  infection ;  proper  physi- 
cal operation,  to  maintain  this  exclusion ;  and 
the  supervision  of  the  human  factor, — "the  man 
behind  the  gun."  A  locomotive  may  be  built 
perfectly  and  be  kept  in  perfect  running  order; 
but  the  locomotive  engineer  himself  is  still  the 
soul  of  the  machine.  Perfect  physical  equip- 
ment and  perfect  physical  maintenance  of  pub- 
lic utilities  related  to  the  spread  of  disease, 
are  enormously  important,  yet  they  are  less  im- 
portant than  the  men  who  are  to  be  in  actual 
control  of  the  actual  operations.  No  better 
illustration  of  this  can  be  offered  than  the  fact 
that  the  milk  supply  from  tested  highbred  cows, 
palatially  housed,  scrubbed,  and  vacuum-cleaned, 
has  carried  disease  and  death  to  its  consumers, 
because  one  man  engaged  in  handling  the  milk 
conveyed  infection  to  it  by  the  intimate  personal 
contact  which  no  organization  or  mechanism  can 
wholly  avoid. 

Some  of  the  worst  water  epidemics  we  have 
ever  had  were  due  to  the  human  factor  failing 
at  the  critical  moment.  This  failure  of  the  human 
factor,  which  is  a  commonplace  in  accidents  by 
rail  or  boat,  applies  equally  to  all  branches  of 
public  health,  although  the  usual  belief  is  that 

79 


almost  any  person  is  good  enough  to  conduct 
public  health  work. 

The  reason  for  this  commonly  accepted  belief 
is  probably  that  public  health  work  for  the  pre- 
vention of  disease,  or  for  the  general  physical 
advancement  of  the  race,  is  often  confused  with 
certain  measures  which  make  merely  for  ease 
or  comfort ;  and  it  is  human  nature  to  look  down 
upon  those  whose  services  minister  to  our  com- 
fort. We  forget  that  by  our  slaves  we  rise  and 
by  our  slaves  we  fall.  Too  often  they  and  their 
procedures  are  neglected  so  long  as  comfort  and 
convenience  are  supplied  by  them  without  too 
much  trouble  to  those  who  enjoy  the  fruits  of 
their  labor. 

To  define  public  health  engineering  in  the  light 
of  the  new  public  health  principles,  it  must  be 
defined  as  such  w^ork  as  deals  through  the  physi- 
cal construction  and  operation  of  physical  sur- 
roundings and  mechanisms  with  (a)  the  preven- 
tion of  disease  or  (b)  with  the  advancement  of 
physical  bodily  welfare.  If  we  include  also,  as 
is  sometimes  done,  all  such  operations  as  con- 
duce, however  indirectly,  to  any  kind  of  "racial 
advancement,"  we  must  add  all  engineering 
works,  architecture,  street  paving,  acoustic  prop- 
erties of  public  buildings,  the  size  of  doorways, 
fire-escapes,  bridges,  railways,  and  every  other 
form  of  modern  artificial  surroundings,  and  with 
them  their  corollaries,  noise,  dust,  the  smoke 
nuisance,  etc. 

The  line  between  true  sanitary  measures  and 
those  for  securing  mere  comfort  or  convenience 
must  be  drawn  somewhere,  and  it  must  be  re- 
membered that  all  "racial  advances''  are  by  no 
means  advancements  of  public  health.  The  rail- 
roads are  of  great  sociological  importance  to  the 

80 


race,  but  they  often  carry  disease  where  disease 
would  not  have  traveled  otherwise.  Every  ad- 
vance which  leads  to  greater  prosperity  leads  to 
more  intermingling  of  people  and  to  wider  social 
relations  and  so  involves  a  wider  exchange  of 
bodily  discharges.  The  installation  of  a  public 
water  supply  system  adds  great  comfort,  con- 
venience, decency,  and  physical  welfare,  but  it 
also  provides  a  route  of  infection  which  leads 
directly  into  every  home.  If  you  put  all  your 
eggs  into  one  such  basket,  you  must  watch  that 
basket.  A  sewerage  system,  by  getting  rid  of 
outdoor  toilets,  greatly  conduces  to  decency,  com- 
fort, and  cleanliness,  and  even  obviates  one  dan- 
ger of  disease  (carriage  of  toilet  discharges  by 
flies  from  the  outdoor  closet)  ;  but  it  also  con- 
centrates all  those  discharges  into  one  foul  union 
and  the  disposal  of  this  often  endangers  other 
communities.  There  is  no  real  advance  in  trans- 
ferring the  burden  of  infectious  disease  from  one 
community  to  another  by  passing  the  sewage  on 
from  one  water  supply  to  another.  Hence  the 
true  province  of  the  Public  Health  Engineer  is 
not  the  mere  advocacy  and  construction  of  great 
engineering  enterprises,,  but,  rather,  the  super- 
vision of  the  construction  of  such,  to  see  that  the  i 
public  health  harm  they  may  do,  if  the  public/ 
health  view  be  neglected,  is  properly  avoided,  so^ 
far  as  physical  constructign  or  operation  may 
avoid  it. 

The  Public  Health  Engineer  is  not  therefore, 
or,  rather,  should  not  be,  merely  \vhat  the  popu- 
lar imagination  makes  him,'a  man  of  sewer  pipes 
and  concrete ;  of  water-meters,  manholes,  and 
pumps.  The  New  Public  Health  Engineer  will 
be  a  man  of  keen  eye  to  see  those  features  in  all 
community  construction  work  which  may  conduce 

81 


to  greater  exchange  of  discharges,  a  man  who 
knows  just  what  is  needed  for  prevention  of  dis- 
ease in  such  ways,  and  therefore  can  both  pro- 
vide proper  precautions  and  at  the  same  time 
avoid  unnecessary  and  expensive  precautions. 
The  civil  engineer  has  been  defined  as  he  who  can 
do  for  $1.00  what  any  fool  can  do  for  $4.00.  He 
is  a  physical  economist.  He  insists  on  physical 
safety,  but  zvithin  that  limit  knows  best  how  to 
achieve  the  needed  safety  without  undue  expendi- 
ture. The  Public  Health  Engineer,  dealing  with 
water  supplies,  sewage  disposal,  etc.,  does  just 
this  thing,  (pe  guarantees  sanitary  safet3%7and 
within  that  limit  he  guarantees  it  for  less  money 
than  the  ordinary  builder.  An}-  keen  student  of 
infectious  diseases  can  generalh'  see  the  grosser 
faults  in  a  supply  which  permit  infection.  The 
Public  Health  Engineer  is  a  specialist.  He  sees 
these  faults  very  much  more  quickly  and  surely ; 
if  they  are  obscure  he  has  the  skill  and  knowl- 
edge to  disentangle  them ;  and  when  he  finds 
them,  he  knows  how  to  correct  them. 

The  Public  Health  Engineer  is,  or  should  be, 
much  more  than  this,  however.  He  is  the  only 
public  health  worker  whose  initial  professional 
training  necessarily  makes  of  him  a  business 
man,  in  the  sense  of  an  administrator  of  opera- 
tions on  schedule  time,  and  with  economy  of  labor 
and  expense.  Those  physicians  who  make  good 
administrators  in  this  sense  do  so  because  they 
learn  it  in  administration,  not  because  of  initial 
professional  training.  This  training  of  the  Pub- 
lic Health  Engineer  makes  him  also  the  best  man 
to  supervise  maintenance  of  public  utilities,  as 
well  as  to  construct  and  equip  them.  Further, 
the  absence  of  training  in  mechanisms  and  ma- 
chinery  so   prominent   in   the   training   of   most 

82 


% 


health  officials,  makes  of  the  Public  Health  En- 
gineer the  only  public  health  man  who  can  deal 
properly  with  the  many  mechanical  devices  for 
modern  handling  of  the  public  routes  of  infec- 
tion, on  the  perfection  of  which  many  lives  often 
depend.  The  hypochlorite  plant,  the  mechanical 
filter,  the  Pasteurizing  device  are  machines. 
However  well  a  physician  may  understand  the 
underlying  biological  principles,  he  cannot  figure 
the  pitch  of  a  cog-wheel  or  find  the  reason  of 
the  filter  "loss  of  head"  without  infinite  and 
wasteful  efifort,  if  at  all. 

The  Public  Health  Engineer  is  in  public  health 
what  the  surgeon  is  in  medicine,  the  "man  of  his 
hands," — the  actual  operator.  Whatever  the  phy- 
sician may  discover  as  surgically  necessary  to  be 
done,  it  is  the  surgeon  who  must  bring  his  skill 
and  knowledge  to  bear  upon  the  doing  of  it.  So, 
although  the  epidemiologist,  the  vital  statistician, 
the  laboratory  man  must  usually  determine  the 
sources  and  routes  of  disease,  it  is  the  Public 
Health  Engineer  to  whom  we  must  all  turn 
wherever  and  whenever  those  sources  or  routes 
can  be  put  out  of  action  by  physical  construction 
or  mechanical  device,  or  when  economic  mal- 
administration of  public  utilities  is  the  real  basis 
of  the  trouble  rather  than  a  physical  condition. 

The  Public  Health  Engineer  is  not,  however, 
as  a  rule,  a  man  of  a  biological  turn  of  mind. 
He  generally  takes  vital  statistics  too  seriously 
and,  lacking  medical  knowledge,  interprets  vital 
statistics  too  mechanically.  His  own"  units  of 
weis:ht,  volume,  and  measurement  are  fixed  and 
definite.  He  has  not  learned  to  scan  the  unfamil- 
iar units  of  disease,  each  by  itself ;  nor  is  it  likely 
that  as  a  class  he  ever  will.  The  spectacle  of  an 
engineer  advising  on  a  strictly  medical  problem 


is  only  less  sad,  if  less  sad  at  all,  than  that  of  a 
medical  man  advising  on  a  strictly  engineering 
problem.  It  is  in  co-operation,  each  perfect  in 
his  own  field,  but  aiding  the  other  with  real  un- 
derstanding of  the  other's  problem,  that  well- 
balanced,  sane  advance  is  made. 

So  far  as  the  five  great  routes  are  concerned, — 
water,  food,  milk,  flies,  and  contact, — the  engi- 
neer has  so  far  found  his  chief  field  in  dealing 
with  water  supplies.  Even  sewage  disposal,  so 
far  as  it  is  a  sanitary  problem,  has  as  yet  been 
chigfly  considered  in  so  far  as  it  might  affect 
the  purity  of  water.  But  in  the  future  the  engi- 
neer must'  also  deal  with  milk  supplies,  their 
production,  transportation,  pasteurization,  disin- 
fection ;  with  the  great  .fly  problem  and  its  chief 
corollary,  the  safe  disposal  of  human  excreta, 
as  well  as  its  minor  corollaries,  garbage  and  ma- 
nure removal.  Finally,  perhaps  chiefly,  he  must 
deal  with  the  great  sociological  factors  on  which 
rests  contact  infection  in  public  meeting-places, — 
the  factory,  the  shop,  the  church,  the  theater,  the 
school,  even  the  tenement  and  the  private  home. 
Above  all,  the  great  engineer  of  the  future  is  he 
who  will  see  with  trained  analytical  mind  and 
act  with  trained  administrative  ability  in  organ- 
izing or  re-organizing  not  one  but  a  dozen  of 
the  many  factors  in  the  modern  complex  of 
society  along  lines  which  shall  in  themselves 
redistribute  concentrated  forces  now  too  closely 
interwoven  for  mutual  good. 

But  there  must  be  more  public  health  in  en- 
c^ineering  rather  than  more  engineering  in  public 
health.  This  series  of  papers  will  have  failed 
wholly  in  pointing  out  the  real  essential  inside 
truth  of  public  health  progress  if  it  leaves  be- 
lief   that    infectious    diseases    can    be    abolished 

84 


M. 


through  any  physical  or  mechanical  means.  The 
great  engineering  operations  of  the  day  have  an 
importance  to  mankind  much  greater  in  socio- 
logical and  economic  lines  than  in  public  health. 
But  the  public  health  end  must  not  be  neglected, 
even  though  we  recognize  that  it  can  never  be  the 
great  end  of  engineering,  because  no  mere  guard- 
ing of  such  routes  of  infection  can  abolish  dis- 
ease, and,  if  it  could,  there  are  far  more  direct, 
drastic,  and  simple  measures  to  be  enforced  in 
other  directions  than  in  the  protection  of  public 
utilities.  Great  engineering  works  are  not  es- 
sential to  the  abolition  of  infectious  diseases, 
but  great  engineering  works  should  be  so  con- 
ducted as  to  secure  what  reduction  in  such  dis- 
eases it  may.  The  ultimate  abolition  of  infectious 
diseases  rests  with  the  supervision  of  the  infec- 
tious individual,  and  no  mere  adjustment  of  sur- 
roundings can  so  affect  his  conduct  as  to  compel 
that  conduct  along  proper  lines.  But  the  public 
health  engineer  through  housing,  organization, 
and  the  proper  construction  and  supervision  of 
public  utilities  can  so  design  the  lines  of  least  re- 
sistance that  the  public,  who  generally  follow 
these  lines,  will  find  them  plain  and  smooth,  but 
hedged  about  with  iron  walls  of  safety. 

SUMMARY 

It  is  a  complete  |mi.snomer  to  designate  as  a 
sanitary  engineer  mm  who  merely  narrows  his 
attention  from  the^^'prmciples  and  practice  of 
engineering  in  general  to  the  application  of  these 
principles  for  the  purpose  of  constructing  water 
supplies,  sewage-disposal  systems,  rendering  of 
garbage,  etc. 

A  man  is  not  a  sanitary  engineer  because  he 
can  lay  down  sewer  pipe  any  more  than  a  man  is 

85 


an  artist  because  he  can  lay  on  paint.  The  PubHc 
Health  Engineer  in  the  true  sense  is  he  who  has 
acquired  so  wide  a  view  of  modern  life,  of  its 
mechanisms,  and  of  the  physical  side  of  man's 
environments,  that  he  can  see  and  act  through 
them  for  man's  physical  protection  not  merely 
from  accident  but  also  from  disease.  He  does  not 
just  build  sewers.  When  he  builds  them,  he 
builds  them  as  part  of  the  great  fabric  of  mod- 
ern life.  His  plans  are  not  merely  so  many  feet 
of  pipe,  at  such  a  price  per  foot :  they  are  adapta- 
tions and  applications  of  great  fundamental  laws 
to  the  physical  advancement  of  mankind. 


\ 


86 


Chapter  VIII 
COMMUNITY  DEFENSE 

THE    PUBLIC-HEALTH    LABORATORY 

The  previous  chapter  discussed  the  relation  of 
the  PubHc  Health  engineer  to  the  protection  of 
man  from  disease,  through  the  construction, 
operation,  and  direction  of  those  public  utilities 
already  proved  to  be,  at  times,  routes  of  infec- 
tion. 

Some  day,  when  we  have  really  determined  the 
conditions  which  truly ,  promote  physical  well- 
being,  as  distinguished  from  those  which  merely 
secure  escape  from  disease,  the  Public  Health 
engineer  will  find  larger  functions  in  a  wider 
field,  the  supervision  of  the  whole  material  sur- 
roundings of  man. 

The  present  chapter  attempts  to  set  forth  the 
relation  of  the  Public  Health  laboratory  man  to  , 
the  same  two  divisions, — to  the  promotion  of 
high  health,  on  the  one  hand,  and  to  the  preven- 
tion of  disease,  on  the  other.  Like  the  Public' 
Health  engineer,  the  Public  Health  laboratory 
man  can  as  yet  contribute  but  little  to  the  for- 
mer, and  for  the  same  reason,  i.  e.,  because  so 
little  is  really  known  about  it.  Like  the  Public 
Health  engineer,  the  Public  Health  laboratory 
man  deals  with  the  prevention  of  disease,  and 
chiefly  with  the  prevention  of  the  infectious  dis- 
eases.    Again,  like  the  engineer,  the  laboratory 

S7 


man  deals  in  part  with  routes  of  diseases,  with 
those  pubhc  utiHties  which  at  times  form  hio^h- 
ways  for  the  exchange  of  infected,  and  unin- 
fected, bodily  discharges.  But,  unlike  the  en- 
gineer, his  work  is  not  confined  to  routes. 

The  Public  Health  laboratory  man,  like  the 
epidemioloq'ist,  deals  also  with  sources,  i.  e., 
with  the  infected  person.  In  some  ways  he  goes 
further  than  the  epidemiologist,  for  he  deals  with 
the  infected  discharges  themselves,  rather  than 
with  the  person  who  discharges  them ;  and,  not 
stopping  even  there,  he  deals  with,  in  those  dis- 
charges, the  very  principles  of  disease  itself, — 
the  individual  little  particles  of  living  matter 
whose  activities  in  the  human  system  produce 
so  much  trouble  for  us  all. 

This  dealing  intimately  with  the  ultimate 
causes  of  disease  is  a  fascinating,  dangerous,  pe- 
culiar life-work,  an  actual  herding,  handling, 
studying,  of  the  very  essences  of  the  dreaded 
plagues  of  old.  What  would  not  the  ancient 
philosophers  and  sages  have  given  for  one 
glimpse  of  a  modern  Public  Health  laboratory 
where  matter-of-fact  men  handle,  in  their  daily 
matter-of-fact  routine,  diphtheria  plants,  typhoid 
plants,  tuberculosis  plants,  etc.,  quite  as  a  student 
farmer  handles  potatoes  or  corn? 

Because  the  little  plants,  or  animals,  perhaps, 
that  produce  many  of  our  common  diseases  are 
as  yet  unrecognized,  for  instance,  scarlet  fever, 
measles,  and  smallpox,  to  name  only  three,  the 
Public  Health  laboratory  man's  chief  daily  duties 
lie  with  typhoid,  diphtheria,  and  tuberculosis. 
These  furnish  the  bulk  of  his  worl^.  His  chief 
services  to  mankind,  in  the  temperate  zone  at 
reast,  consist  in  the  aid  he  gives  in  recognizing 
those  persons  who  are  infected  with  one  of  these 

88 


three  germs  without  showing-  conclusive,  perhaps 
any,  symptoms  of  their  presence.  True,  he  can 
and  does  perform  hke  services  in  other  diseases 
whose  causes  are  recognized — such  as  anthrax, 
bubonic  plague,  cholera,  glanders,  leprosy,  etc. ; 
but  these  are  so  rare  as  to  form  only  a  flavoring 
for  his  daily  grist.  In  the  venereal  diseases,  also, 
the  biological  causes  are  known  and  can  be  rec- 
ognized, but  the  laboratory  man  must  await  the 
development  of  the  growing  public  demand  for 
the  handling  of  these  diseases  on  a  par  with 
other  infections,  the  taking  up  of  these  great 
subjects  by  legislative  and  executive  authorities. 
Until  that  time  comes  the  laboratory  man  can 
proclaim  his  own  readiness  and  point  to  the 
road,  but  he  can  do  little  mor-e. 

With  the  routes  of  infection, — water,  flies, 
food,  milk,  and  contact,^the  laboratory  man  has 
much  to  do,  but,  again  and  for  similar  reasons, 
he  deals  with  these  routes,  in  the  temperate  zone, 
chiefly  when  typhoid,  diphtheria,  or  tuberculosis 
are  involved.  His  functions  in  all  this  work  are 
chiefly  analytic,  i.  e.,  to  find  the  particular  water, 
or  milk,  or  food  which  may  be  dangerous ;  some- 
times to  detect,  if  he  may,  the  presence  in  them 
of  the  deadly  germ  itself. 

Unfortunately,  for  reasons  already  offered  in 
a  different  connection  (see  Chapter  II),  the 
germs  of  disease  are  very  rarely  found  in  water, 
food,  milk,  or  flies.  They  live  so  short  a  life  out- 
side of  the  human,  or  animal,  bodies  which  form 
their  natural  growing-grounds  that  the  labora- 
tory man  seldom  encounjters  them  except  in  the 
body.  The  usual  thing  is,  that  long  before  a 
"sample"  of  water,  etc.,  arrives  at  the  laboratory, 
the  disease  germs  it  may  once  have  held '  are 
dead  or  so  outgrown  by  others  that  the  bes):  lab- 

89 


oratory  methods  must  necessarily  fail  to  find 
them. 

So  little  is  this  understood  •  that  one  of  the 
almost  daily  happening's  in  every  laboratory  is 
the  receipt  of  water,  or  milk,  or  food  (flie^,  for- 
tunately, are  not  often  sent,  as  yet)  from  lay- 
m'^n,  even  from  physicians,  with  the  request  that 
they  be  searched  for  typhoid  or  diphtheria  germs. 

But  consider !  Before  a  given  water  supply 
has  attention  called  to  it  as  a  source  :@|^  typhoid 
fever,  typhoid  fever  cases  usually  must  have  de- 
veloped from  it.  But  typhoid  fever  is  a  disease 
which  does  not  develop  even  its  very  first  symp- 
toms until,  on  an  average,  two  we^s  have 
elapsed  after  the  germs  first  entered  the  body 
from  the  water  supply.  Usually,  another  week 
passes  before  the  physician  is  called  and  perhaps 
another  week,  more  .qften  two  or  three,  before 
the  sample  is  sent ;  therefore  five  weeks  is  perhaps 
the  usual  time  which  has  slipped  away  since  the 
typhoid\erms  zv£re  present  in  the  water  supply, 
before  the  laboratory^^jian  receives  a  sample  from 
it !  Now,  two  weeks  is' probably  the  usual  maxi- 
mum for '  typhoid  germs  to  live  in  water,  even 
if  the  water  be  stagnant  and  in  a  da^k  pl^ce. 
When  it  is  heaving,  changing,  exposed  to  the  sun 
and  wind  and  current,  or  flowing  fast,  as  in  a 
river,  the  life  of  disease  germs  in  it  is  even  short- 
er, and  the  chances  of  their  dispersion  and  dis- 
appearance by  the  mere  physical  losing  of  them- 
selves are  almost  infinite.  To  apply  laboratory 
methods  to  finding  typhoid  germs  in  the  ordi- 
nary sample  of  water  taken  from  the  suspected 
supply  five  weeks  after  the  cases  were  infected, 
would  be  like  shooting  at  the  place  where  a  flock 
of  ducks  had  been  five  weeks  before.  "Hunting 
for    a    needle    in    a    haystack"    is    discouraging 

90 


enough  in  itself,  but  suppose  you  knew  the  needle 
had  been  carefully  removed  before  you  began 
your  hunt ! 

The  laboratory  man  who  examnies  water  does 
so,  not  in  the  hope  of  finding  typhoid  germs, — 
he  does  not  even  try  to  look  for  them,  as  a  rule, — 
but  to  find  certain  other  signs  of  excretory  pol- 
lution. Curiously  enough,  these  signs  are  often 
of  more  real  value  to  Public  Health  than  would 
be  the  finding  of  the  typhoid  germs  themselves, 
were  that  practicable ;  but  to  explain  how  this  is 
would  be  out  of  place  here.  The  point  is  this : 
The  laboratory  tests  of  the  supposed  routes  of 
infection  in  any  given  case  are  made  by  methods 
and  for  ends  wholly  different  from  those  which 
the  public  fondly  imagines.  The  results  obtained 
are  often  far  more  valuable  than  the  public  real- 
izes or  expects.  At  the  same  time,  the  definite- 
ness  of  these  results,  because  of  the  facts  al- 
ready outlined,  are  far  inferior  to  those  obtained 
in  the  laboratory  examination  of  infected  per- 
sons— in  brief,  the  information  from  laboratory 
sources  concerning  "samples"  usually  requires 
elucidation  and  explanation  in  the  light  of  all 
sorts  of  other  information,  sociological,  meteoro- 
logical, topographical,  geological,  etc.  Consider- 
ed thus,  the  laboratory  work  is  nearly  invaluable, 
but,  taken  by  itself,  almost  as  nearly  worthless. 

The  happy  ignorance  displayed  by  those  who. 
think  that  an  analysis  of  water,  or  milk,  or  food, 
even  the  most  thorough,  can  in  itself  and  by  it- 
self give  useful  sanitary  information  is  equalled 
only  by  the  joyful  confidence  of  the  southern 
darkey  in  a  rabbit's  foot.* 


*The  British  Medical  Association  at  its  annual  meet- 
ing-, held  this  year,  passed  the  following-  resolution: 
"That  this  con-joint  meeting  of  the  sections  of  State 
Medicine  and  Bacteriology  unanimously  desires 
strongly  to   urg-e   that  no  opinion  as  to  the  quality  of 

91 


The  true  position  of  the  laboratory  in  the  co- 
ordination of  pubHc  health  workers  which  will 
rule  in  future  organization,  has  been  achieved 
but  seldom. 

The  Public  Health  laboratory  man  of  today 
has  ceased  to  be  the  leader  in  public  health  en- 
deavor which  he  once  was,  partly  because  he  has 
been  swamped  with  routine  work  in  the  lines 
he  has  himself  developed,  but  chiefly  because  he 
is  a  laboratory  man  and  because  the  very  na- 
ture of  his  work  has  kept  him  indoors,  out  of 
and  apart  from  the  stirring  fields  of  human  life 
in  being.  Perfect  enough  in  his  own  technic, 
he  has  perforce  lost  touch  with  all  but  his  own 
work,  and  other  lines  of  public  health  more 
closely  involved  with  the  outer  world,  have  pass- 
ed ahead  of  his. 

The  laboratory  man  must  get  out  into  the  ac- 
tual daily  lives  of  the  people  and  communities 
he  serves.  He  must  know  outside  conditions  as 
well  as  those  in  the  laboratory.  He  must  work 
more  closely  with  the  engineer  and  the  epidemio- 
logist. He  has  his  own  place  which  they  can  fill 
no  more  than  he  can  fill  theirs,  but  he  must  un- 
derstand their  work,  and  they  his,  much  better 
than  at  present. 

Moreover,  the  engineer  and  the  epidemiologist 
suffer  from  the  present  disassociation  of  the  lab- 
oratory quite  as  much  as  does  the  laooratory  man 
himself.  Field  work  moves  lamely,  oftentimes, 
from  lack  of  laboratory  knowledge, j"ust  as  lab- 
oratory work  is  oftentimes  inert  from  lack  of 
field  knowledge.  During  the  last  few  years  the 
frequent  transfer  of  laboratory  men  into  the  field 

a  water  for  dietetic  purposes  should  be  arrived  at  on 
bacteriological  evidence  without  a  local  and  topo- 
graphical inspection  of  the  sources  of  the  supply  made 
by    a    competent    observer." 

92 


work  of  epidemiology  and  engineering  has 
evolved  a  set  of  men  who  recognize  this  fully. 
But  it  is  not  by  transferring  laboratory  men  to 
other  fields  that  the  laboratory  can  be  developed. 
It  is  by  putting  the  laboratory  itself  into  the  field 
— and  only  so — that  this  can  be  accomplished. 

In  field  work,  and  in  research,  so  much  neg- 
lected of  late,  the  laboratory  man  will  find  his 
future,  and  he  will  not  deal  solely,  as  at  present, 
with  infectious  diseases.  True,  the  venereal  dis- 
eases must  be  added  to  the  present  list  of  those 
for  which  routine  laboratory  facilities  are  pro- 
vided. But  some  non-infectious  diseases  may  be- 
come preventable  diseases,  if  their  causes  are  dis- 
covered, and  the  Public  Health  laboratory  of  the 
future,  acting  in  conjunction  with  the  physiolo- 
gist and  the  pathologist,  may  find  therein  useful- 
nesses now  undreamed  of.  Finally,  as  we  slowly 
learn  the  true  personal  hygiene  of  food,  cloth- 
ing, sleep,  exercise,  etc.,  the  Public  Health  labor- 
atory will  take  its  share  in  the  greatest  but  least 
developed  of  all  Public  Health  procedures,  name- 
ly, the  physical  regeneration  of  the  race. 

SUMMARY 

The  Public  Health  laboratory  finds  its  chief 
functions  today  in  the  detection  of  infectious  per- 
sons (sources)  and  in  the  identification  of  infect-- 
ed  things  (routes)  as  a  means  to  the  end  of  abol-; 
ishing  those  sources  and  blocking  those  routes. 
The  average  public  health  laboratory  has  been 
swamped  with  routine,  cribbed,  cabined,  and  con- 
fined until  useful  research  has  almost  died  out 
and  real  knowledge  of  outside  conditions  has 
been  lost.  The  engineer  and  the  epidemiologist 
have  progressed  fast  and  far  by  active  contact 
with  the  needs  of  the  outside  world,  and  the  lab- 
oratory can  attain  its  proper  future  only  by  like 
development. 


Chapter  IX 
COMMUNITY  DEFENSE 

THE    PUBLIC    HEALTH    STATISTICIAN 

In  the  development  of  the  new  pubhc  health 
principles,  the  laboratory  came  first.  It  dealt 
with  the  causes  of  disease  at  first  hand,  as  well 
as  with  their  sources  and  their  routes  of  trans- 
mission. On  laboratory  findings  all  modern  pub- 
lic health  is  based,  although  in  practice  the  lab- 
oratory is  necessarily  limited,  for  daily  service, 
to  those  diseases  the  causes  of  which  are  known. 

But  in  its  earlier  work,  the  laboratory,  inher- 
iting somewhat  the  environmental  teachings  of 
the  older  school,  paid  more  attention  to  routes 
than  it  did  to  sources,  especially  to  the  routes 
constituted  by  (a)  water  and  (b)  general  sur- 
roundings. This  focused  attention  on  (a)  san- 
itary engineering  and  (b)  disinfection.  It  was 
in  the  earlier  laboratory  period  that  the  sanitary 
engineer  and  the  disinfector  developed  highly.  It 
is  true  that  the  engineer  deals  almost  solely  as 
yet  with  but  one  route,  water ;  and  that  therefore 
his  eflforts  necessarily  relate  almost  solely  to  the 
intestinal  infections,  mainly  to  typhoid  fever. 
Nevertheless,  so  valuable  were  his  services  in 
reducing  this  disease,  that  engineering  work  was 
hailed  at  one  time  as  the  solution  of  all  public 
health  questions.  Now  the  epidemiologist  leads 
the  van,  because  he  deals  not  with  some  routes, 

94 


of  some  infectious  diseases,  but  with  all  sources 
of  all  infectious  diseases. 

STATISTICS  AS  THEY  WILL  BE 

But,  through  the  work  of  the  laboratory  man, 
the  engineer  and  the  epidemiologist  has  for  long 
been  heard  a  still,  small  voice,  offering  a  frame- 
work to  bind  them  all  together — to  give  coher- 
ence, correlation,  and  proportion — to  outline  the 
future,  as  well  as  to  record  the  past,  and,  above 
all,  to  direct  the  present.  This  was  the  voice  of 
the  vital  statistician.  Much  abused,  laughed  at, 
neglected,  he  is,  or  will  be,  guide,  map-maker, 
intelligence-department,  all  in  one;  he  is,  or  will 
be,  like  the  cost-of-production  scientific  manager 
of  modern  business,  *'the  most  indispensable  man 
on  the  staff." 

True,  his  professional  ancestors  were  helpless 
old  gentlemen,  raising  their  feeble  voices  in  very 
feeble  chants.  A  dry-as-dust  historian  of  the 
wars  of  ancient  Greece  could  lend  more  aid  to  a 
modern  football  team  than  the  old-time  statisti- 
cian furnished  to  public  health  endeavors.  Even 
now  the  new  vital  statistician  is  scarcely  yet  full- 
born.  Hardly  a  health  department  now  in  ex- 
istence collects  in  full  or  uses  to  full  advantage 
one-tenth  the  information  that  it  really  needs. 
(A  notable  exception  should  "be  recorded  here,  the 
Richmond  (Va.)  Health  Department  under  E. 
C.  Levy.)  The  laboratory  man  has  made  some 
good  statistics  in  his  own  field ;  so  has  the  sani- 
tary engineer — sometimes,  alas,  not  wisely,  but 
too  well ;  the  epidemiologist,  also,  from  sheer 
necessity:  but  the  new  vital  statistician  has  only 
begun  to  move.  When  he  does  move,  fully 
equipped,  alert,  he  will  systematize,  organize,  and 
use  the  rich  data  so  far  largely  wasted,  this  very 

95 


life-blood  of  public  health  endeavor,  accurate, 
complete  information  concerning  the  way  human- 
ity reacts  to  human  ills.  Internal  public  health 
organization  has  been  like  the  old-time  factory, 
full  of  good  workmen,  but  each  working  only 
his  own  line,  with  no  one  person  knowing  much 
about  the  business  as  a  whole.  At  the  end  of  the 
year  the  business,  drifting  along,  perhaps  showed 
a  doubtful  profit,  perhaps  a  loss,  but  so  long  as 
bills  and  wages  were  somehow  paid,  who  cared? 
Public  health  requires  exactly  the  kind  of  man 
who  has  changed  the  face  of  business  in  the  last 
fifteen  years,  a  man  who  understands  all  parts  of 
it,  but  does  none  himself ;  a  man  who  knows  costs 
in  each  department  in  proportion  to  production, 
and  where  to  cut  cost,  increase  production,  save 
time,  unnecessary  work,  and  waste  in  general ; 
alas,  in  health  departments,  a  man  to  stop  the  one- 
half,  now  done  uselessly  in  wholly  wrong  direc- 
tions and  to  force  development  of  the  other  half, 
now  much  neglected  or  left  undone  completely. 
It  is  the  vital  statistician  who  must  do  this : 
collect  the  facts  and  set  them  forth  inexorably, 
with  mathematical  precision.  When  it  is  done, 
our  health  departments  will  no  longer  use  up 
$30,000  for  garbage,  with  the  probability  that  not 
a  single  life  will  be  saved  thereby,  while  spend- 
ing $12,000  on  all  other  health  department  ef- 
forts combined.  Nor  will  a  health  department 
spend  for  terminal  disinfection  one-tenth  its  an- 
nual appropriation,  to  save  no  lives  at  all,*  while 
using  but  one-fiftieth  its  appropriation  for  tuber- 
culosis, which  kills  five  times  as  many  people  as 
all  the  diseases  usually  ''disinfected"  put  to- 
gether. 


*In  tuberculosis,  where  terminal  disinfection   would   be   valuable 
it  is  not  often  done. 

96 


It  will  be  said :  "You  are  confusing  vital 
statistics  with  health  department  finance ;  vital 
statistics  deal  with  deaths,  not  money."  Ex- 
actly— and  that  is  just  exactly  what  is  wrong 
with  them.  Vital  statistics  are,  in  short,  not 
vital;  they  deal  with  Death,  not  Life,  with  the 
"finished  product"  only  of  our  slack,  slipshod 
methods.  They  ought  to  deal,  not  with  the  dead, 
but  who  they  were,  and  why  and  how  they  died, 
and  why  they  were  not  saved.  Suppose  the  fac- 
tory manager  knew  at  the  end  of  the  year  mere- 
ly his  total  product !  Suppose  that  even  this 
piece  of  information  related,  not  to  the  way  busi- 
ness went  last  year,  but  to  the  way  it  went  five 
years  before.  "Historical  records,  and  mighty 
poor  at  that,"  a  modern  public  health  man  said 
in  bitter  scorn  of  the  statistics  of  a  neighboring 
state.  The  modern  scientific  manager  must 
know  not  just  the  total  product,  though  he  must 
know  that,  and  to  the  minute,  not  to  five  years 
before ;  he  must  know  also  all  about  the  product, 
the  kind,  the  quality,  the  cost,  and  why  it  is  not 
better  for  the  price.  The  modern  vital  statis- 
tician must  know  not  only  deaths,  but  why  the 
health  department  is  not  stopping  them ;  what 
its  funds  are ;  how  they  are  spent  or  wasted ; 
what  work  is  being  done ;  how  much  of  value 
each  division  does ;  and  all  to  the  one  end  of 
saving  life,  not  to  the  end  of  stopping  nuisances, 
removing  garbage,  or  cleaning  streets — all  admir- 
able ends  no  doubt,  but  not  life-saving  ends. 

But,  it  will  be  said,  "Very  well,  but  you  are 
wrong  in  stating  that  Vital  Statistics  deal  with 
Deaths.  They  deal  with  more  than  Deaths — 
they  deal  with  Births  and  Marriages  and  con- 

97 


tagious  diseases  also."     Yes,  nominally ;  but  to 
what  useful  end  for  public  health  ?'^' 

"Birth  records  quite  often  affect  inheritance 
of  estates  in  later  years."  True,  and  very  useful 
to  the  inheritor  they  are  when  the  time  comes, 
but  what  has  that  got  to  do  with  saving  life  now  ? 
Marriage  records  also  are  invaluable  in  their  own 
way,  but  they  do  not  reduce  tuberculosis  one- 
tenth  of  a  tenth  per  cent.  Contagious  disease 
reports,  then?  Surely  they  are  important?  Yes, 
but  not  as  they  are  now  collected.  Misleading 
information  is  sometimes  worse  than  none  at  all. 

STATISTICS  AS  THEY  ARE 

The  best  way  to  show  what  public  health  vital 
statistics  as  they  are  today  mean,  or  do  not  mean, 
is  to  give  the  story,  true  to  life,  as  anyone  who 
knows  will  quickly  see,  of  the  very  basis  of  such 
statistics,  the  actual  facts  as  they  occur  amongst 
the  people. 

Mrs.  Anybody  says  to  Mr.  Ditto:  'T  am 
afraid  Tommy  has  scarlet  fever ;  I  think  he  must 
have  caught  it  when  he  was  in  the  city."  "Call 
Dr.  A."  "Yes,  but  they  say  he  will  report  it, 
if  it  is  scarlet  fever.  I'm  nearly  wild  now  with 
work.  When  the  children  are  at  school  all  day 
I  manage  somehow ;  with  you  and  the  children 
quarantined  at  home  for  a  month  I  should  go 
insane.  I'll  call  Dr.  B. ;  they  sav  he  never  re- 
ports anything.  I'll  tell  the  neighbors  it  is  scar- 
let rash.  That's  not  a  lie.  It's  a  rash,  and  it 
certainly  is  scarlet.  I'll  let  the  children  go  to 
school,  but  I'll  keep  every  one  away  from  Tom- 
my. I'd  hate  to  think  any  other  child  <:rot  it 
from  our  children,  but  I  guess  that  will  be  all 

♦Birth  records,  if  they  led  to  immediate  investiga- 
tion to  see  that  the  child  was  cared  for  properly,  would 
bfi    true   public   health   data. 

98 


right.  Tommy  is  not  very  sick  yet.  Don't  go 
telling  anyone  he  is  sick.  I'll  tell  the  children 
not  to,  either.  We  don't  want  to  have  the  milk- 
man or  the  grocer  afraid  to  call." 

So  Mrs.  Anybody  plans,  and  so  it  is  carried 
out.  But  her  heart  is  bigger  than  her  head,  and 
her  plans  go  strangely  awry. 

She  puts  Tommy  in  a  room  by  himself  and 
runs  over  to  a  neighbor's  for  an  egg  or  a  cup 
of  flour.  When  she  comes  back  the  other  child- 
ren are  lined  up  in  Tommy's  room,  solemnly  in- 
specting the  rash  he  proudly  demonstrates  to 
them.  Next  morning  Tommy  is  ''real  sick," 
and  after  breakfast  the  mother  puts  up  the  other 
children's  school  lunches  alternately  with  running 
in  to  Tommy's  room  to  give  him  water  or  to  hold 
the  basin  while  he  vomits  or  just  to  kiss  and 
soothe  him. 

Poor,  loving,  hard-working  mother !  She 
has  done  the  same  through  all  the  ages,  taking 
infected  discharges  from  the  sick  child,  on  her 
hands  to  put  in  the  other  children's  food! 
No,  she  won't  kiss  them  goodbye ;  she  has  been 
kissing  Tommy ;  that  is,  she  won't  kiss  any  but 
the  smallest  one,  who  looks  nearest  to  crying. 
That  one's  mouth  she  wipes  with  her  apron 
before  she  kisses  it — she  does  not  zuipe  her  own! 
Not  that  wiping  either  matters,  for  Tommy's 
mouth  discharges  are  already  in  the  lunch  the 
little  one  marches  out  with,  under  its  arm. 

About  10  A.  M.,  the  empty  house  and  the  wail- 
ing child  get  on  the  mother's  nerves.  So  she  calls 
in  a  neighbor.  "Tommy's  sick.  I  want  to  go 
to  the  store  to  telephone  the  doctor.  It's  only 
scarlet  rash.  I  won't  be  gone  more  than  a  min- 
ute, but  I'm  afraid  he'll  get  out  of  bed  or  some- 
thing.    Will  you  keep  an  eye  on  him?" 

99 


The  neighbor  comes  in,  the  baby  on  her  arm, 
for  is  it  not  scarlet  rash?  But  prudence  strikes 
her  suddenly,  and  she  sets  the  baby  on  the  floor 
before  she  peeks  in  at  Tommy.  "Hullo !"  "Hul- 
lo, Mrs.  Neighbor!"  a  feeble  little  voice  replies. 
She  steps  in  further,  leaving  the  door  open  to 
keep  an  eye  on  baby.  "Well,  Tommy,  how  do 
you  feel?"  "Not  very  well,"  and  he  begins  to 
vomit.  She  snatches  a  basin,  holds  his  head,  and 
in  a  moment  surrenders'  him  to  his  mother,  and 
then  takes  her  baby  hurriedly  home.  A  speck  of 
vomit-spray  has  hit  her  hand.  She  did  not  no- 
tice it.  The  baby's  fingers  rest  on  it  a  moment, 
before  it  is  dry ;  a  minute  later  the  baby  sucks 
that  finger.  At  home  she  sets  the  baby  down 
and,  conscience-smitten,  changes  her  dress  {she 
does  not  wash  her  hands!)  and  thereafter  feels 
all  right  again  because  she  thinks  that  nozv  she 
can't  give  it  to  anyone,  even  if  it  is  scarlet  fever ; 
besides,  the  doctor  said  it  was  scarlet  rash. 

Meantime,  Mr.  Anybody,  summoned  by  his 
wife,  hurries  home  in  terror,  finds  Tommy  still 
quite  alive,  growls,  fusses,  brings  in  some  wood, 
pumps  a  little  water,  and  then  steps  into  Tom- 
my's room,  "just  inside  the  door  for  a  minute," 
before  going  down-town  again.  Tommy,  with 
feverish,  flushed  face  and  heavy  eyes  under  his 
tousled  hair,  calls  feebly,  "My  daddy,  my  dad- 
dy" ;  and,  of  course,  Mr.  Anybody  steps  to  his 
bedside  to  pat  his  head  and  kiss  him,  before 
hurrying  back  to  business. 

That  night  Tommy  is  worse ;  sorrow  is  on  the 
family  in  earnest.  Next  morning  Tommy  is 
much  better ;  the  prayers  and  tears  of  the  night 
before  are  forgotten;  the  mother,  weary  but  joy- 
ful, lets  the  other  children  in  to  see  him;  "just 
for  a  minute  now.  but.  anyway,  he  is  so  much 

100 


better" ;  and  they  all  race  out  to  school,  shouting 
and  laughing. 

About  five  days  later,  Susan,  the  youngest,  is 
not  feeling  very  well  towards  evening,  vomits 
during  the  night,  is  delirious  next  morning,  with 
sore  throat,  swollen  neck,  and  rash ;  and  Dr.  B. 
comes  again.  Serious  measures  are  taken.  The 
other  children,  in  tears,  are  spirited  away  to  a 
cousin's  house  to  stay  lest  they  should  get  it,  and 
because  the  mother  can't  stand  the  strain  of 
nursing  the  sick  and  caring  for  the  well  also. 

Tommy  has  had  it  mildly,  and  by  this  time  is 
up  and  about,  wandering  disconsolately  through 
the  empty  house.  To  all  inquirers  the  mother 
bravely  maintains  that  Susan  has  only  the  scarlet 
rash  and  tells  them  Tommy  will  go  back  to 
school  in  a  day  or  two.  'T  just  sent  the  other 
children  away  because  they  were  so  noisy,"  she 
explains  guiltily,  wishing  very  earnestly  that  it 
was  really  so. 

Next  day  Susan  is  better.  (I  am  writing  this 
— and  therefore  I  make  it  thus.  In  real  life, 
poor  little  Susan  often  dies,  instead.)  Every- 
one is  cheerful  again.  Tommy  is  sent,  very  un- 
obtrusively, to  school  because  ''he  mopes  at 
home,  without  a  soul  to  play  with."  He  is  be- 
ginning to  peel,  and,  in  a  day  or  two,  is  in  much 
demand  amongst  his  schoolmates,  presenting 
them  with  souvenirs  of  flakes  of  skin  they  treas- 
ure as  curiosities.  Not  that  these  scales  do 
harm,  despite, the  old  beliefs.  It  is  not  the  peel- 
ing, which  everybody  sees,  that  does  the  mischief, 
but  the  unnoticed  slightly  red  sore  throat  that 
Tommy  carries  with  him,  and  from  which  he 
infects  his  hands  (and  everyone  he  touches)  and 
shoots   out   infection   in   his   mouth-spray   as   he 

101 


chants  his  lesson,  or  whispers  across  the  aisle, 
or  sing's  in  class. 

And  so  the  old,  old  story  works  itself  out  in- 
exorably. One  of  the  other  children,  staying  at 
the  cousin's,  develops  a  slight  sore  throat.  Were 
there  an  epidemiologist  at  hand,  posted  on  the 
history  of  the  child,  to  scan  the  enlarged  papil- 
lae of  the  tongue,  note  the  large  glands,  and  see 
the  filmy  membrane  on  the  tonsils,  the  case 
would  be  recognized  as  scarlet  fever,  sine  erup- 
tione,  i.e.,  without  a  rash.  But  as  it  is  ''it's 
only  a  sore  throat."  No  physician  sees  her,  be- 
cause the  cousin  argues  thus:  "If  it  were  my 
child,  I'd  have  in  Dr.  A.,  but  Mrs.  Anybody 
wouldn't  thank  me  for  running  up  another  bill 
here,  unless  the  child  is  really  ill ;  she's  having 
Dr.  B.  now,  for  Susan,  twice  a  day.  I'll  wait  a 
day  or  two,  anyway." 

The  sore  throat  mends,  and  the  cousin  feels 
she  made  a  good  judgment.  But  meantime  the 
sore-throat  girl  has  been  sleeping  with  the  cous- 
in's little  girl,  and  she  develops  it,  too,  but  it  also 
passes  off.  Then  a  week  later,  the  cousin's  little 
girl's  school-chum,  in  a  different  school  from 
Tommy's,  has  scarlet  fever  proper.  Dr.  A.  at- 
tends, and  reports  it.  The  Health  Department 
puts  a  placard  up ;  the  children  are  kept  out  of 
school ;  the  father  is  kept  at  home ;  the  whole 
population  turns  its  eyes  to  that  family  and  wour 
ders  where  they  got  it.  The  village  wiseacres, 
over  the  village  bar,  remind  each  other  of  the 
slough  behind  the  house,  or  that  the  garbage  from 
the  family  was  never  removed  all  summer.  They 
say  the  well  is  shallow,  ''nothing  but  surface 
water,"  or  the  house  is  damp,  or  too  much  shut- 
in  by  trees,  or  any  other  fatuous  foolishness  that 
enters  their  empty  heads.     The  mayor  gives  out 

102 


a  statement  to  "allay  popular  excitement."  He 
brands  as  malicious  all  statements  that  scarlet 
fever  is  rampant.  There  is  but  one  "sporadic 
case,"  originating  no  one  knows  how.  It  is  care- 
fully quarantined,  and  "the  Health  Department 
believes  the  outbreak  is  well  in  hand  and  prac- 
tically stamped  out."  The  Women's  Club  de- 
mands the  fumigation  of  the  schools ;  and  the 
epidemiologist,  if  he  were  only  present,  would 
gaze  reflectively  at  Tommy's  slight  red  throat, 
and  gnash  his  teeth,  and  swear.*  Poor  Dr.  A., 
who  only  did  his  duty,  is  blamed  for  all  the 
trouble ;  and  Dr.  B.  keeps  mum.  When,  pres- 
ently, Dr.  C.  is  called  to  one  of  Tommy's  school- 
mates, he  hesitates.  He  has  not  seen  much  scar- 
let fever,  and  he  thinks,  "perhaps  it  is  scarlet  rash 
— whatever  that  may  be."  He  attends  the  child 
two  or  three  days,  and  then  he  begins  to  ponder 
whether  or  not  he  had  not  best  put  the  responsi- 
bility on  the  Board  of  Health;  so  at  last  he  calls 
up  Dr.  D.,  the  Health  Officer.  But  Dr.  D.  has 
troubles  of  his  own.  "Do  you  say  it  is  scarlet 
fever?"  "Well,  I  don't  know.  I  want  you  to 
go  and  see."  The  H.  O.  is  perplexed.  He  does 
not  want  the  reputation  of  finding  a  second  case, 
after  the  Mayor  has  stated  that  there  is  only 
one ;  so  he  tells  Dr.  C. :  "H  you  report  it,  I'll 
placard  the  house,  but  I  don't  want  you  to  report 
it,  if  you  are  not  sure."  At  this  Dr.  C.  waits  a 
day  or  two  more,  but  finally  reports  it.  Mean- 
time a  week  of  association  of  the  other  children 
with  the  sick  one  has  elapsed,  because  Dr.  C.  did 
not  quite  know  the  finer  points  in  recognizing 
mild  scarlet  fever  early. 


*Editor's  Note. — We  regret  the  epidemiologist  should 
do  this,  but  we  propose  to  give  the  facts,  no  matter 
whom  it  hits.  Besides,  we  do  not  blame  him  much  un- 
der the  circumstances. 

103 


By  this  time,  between  the  unconscious  activ- 
ities of  Tommy  and  Susan,  who  are  back  at 
school,  well  oiled  by  Dr.  B.'s  advice,  to  keep  the 
scales  from  showing,  and  of  Susan's  sister  and 
the  cousin's  little  girl  (none  of  them  recognized 
officially  as  scarlet  fever),  some  twenty  or  thirty 
children  in  the  two  schools  have  been  infected. 
Some  of  the  pupils  have  had  scarlet  fever  before 
and  so  escape  this  time.  In  others  the  disease  is 
mild  and  passes  unnoticed.  In  others  "scarlet 
rash"  develops.  But  several  develop  frank  scarlet 
fever,  not  to  be  denied  even  by  Dr.  B.,  who,  to 
give  him  credit,  has  begun  "to  get  a  little 
scared,"  and  so  reports  one  or  two  well-marked 
cases  to  relieve  his  conscience.  Two  or  three 
deaths  occur,  and  then  the  schools  are  closed, 
but  not  the  Sunday-schools,  or  churches,  or  pri- 
vate sociables,  or  moving  pictures,  and  so  it 
drifts. 

Now,  see  how  all  this  aflfects  vital  statistics. 
The  Health  Department,  in  its  annual  statement, 
gives  as  the  first  case  that  school  chum  of  the 
cousin's  little  girl.  But  we  know  that  there  were 
four  cases  before  that — Tommy  and  Susan,  and 
Susan's  sister,  and  the  cousin's  little  girl — but 
these  do  not  go  down  upon  the  books  at  all. 
The  Health  Department  adds  thirteen  more 
cases ;  that  is,  all  those  cases  attended  by  Dr.  A.-, 
faithful,  conscientious  man ;  about  half  of  Dr. 
B's  cases,  those  he  had  after  he  "got  scared" ; 
and  some  of  Dr.  C's,  but  only  those  he  was  abso- 
lutely certain  of,  not  knowing  scarlet  fever  very 
well.  Dr.  D.  had  no  cases,  because  being  health 
officer,  the  mothers  felt  that  he  would  have  to  re- 
port them,  and  so  did  not  call  him. 

The  fact  is,  that  any  epidemiologist  would  find 

104 


that  there  were  forty  cases,  but  the  books  show 
fourteen. 

Then  consider  the  deaths.  Two  are  reported 
properly  as  due  to  scarlet  fever.  But  one  of  Dr. 
B's,  really  scarlet  fever,  not  quarantined  while  ill, 
is  reported  ''acute  Bright's  disease,"  because  the 
doctor  dare  not  say  it  died  of  scarlet  fever  after 
treating  it  a  month  without  reporting  it.  It  is 
quite  true  the  child  had  Bright's  disease,  but  it 
had  Bright's  disease  because  it  had  scarlet  fever. 
Another  dies  of  meningitis,  due  to  middle-ear 
infection,  the  result  of  scarlet  fever,  but  being 
meningitis,  this  death  also  goes  in  a  different^ 
column.  The  more  or  less  spoiled  ears  and  the 
more  or  less  spoiled  kidneys  of  twenty  other 
children  who  recovered  never  are  reco-rded  on 
the  books  at  all. 

Hence,  fourteen  cases  where  there  should  be 
forty;  and  two  deaths,  where  there  were  really 
four,  are  recorded  officially  as  scarlet  fever. 

This  instance  exemplifies  practically  the  whole 
situation ;  mild,  unrecognized,  and  concealed 
cases ;  cases  to  which  physicians  are  not  called  at 
all ;  mistaken  diagnoses ;  a  superficial  report  cov- 
ering a  few  of  the  severer  cases  only;  death  re- 
ports correct  so  far  as  they  go,  but  not  showing 
the  relation  of  the  death  to  the  preceding  dis- 
ease. This  occurs,  not  occasionally  in  a  few 
communities,  with  scarlet  fever  only,  but,  almost 
every  time,  in  almost  every  community,  with  al- 
most every  one  of  the  infectious  diseases. 

The  returns  from  Anybodyville  are  small  in 
number,  it  is  true;  but  multiply  these  by  all  the 
similar  communities  which  make  similar  returns. 
Anybodyville  reports  two  deaths  and  fourteen 
cases  from  scarlet  fever,  where  there  were  four 
deaths    and    forty    cases.     This    is    "only"    two 

105 


deaths  and  twenty-six  cases  wrong.  But  if  one 
thousand  communities  report  similarly,  our  sta- 
tistics are  wrong  two  thousand  deaths  -  and 
twenty-six  thousand  cases. 

Moreover,  see  how  the  percentages  are  twisted 
and  tangled.  Two  deaths  from  fourteen  cases 
is  about  14  per  cent.  Two  deaths  from  forty 
cases  is  5  per  cent.  Four  deaths  from  fourteen 
cases  is  28  per  cent.  Four  deaths  from  forty 
cases  is  10  per  cent.  When  we  remember  that 
the  number  of  cases  of  scarlet  fever,  and  of 
other  diseases,  is  often  calculated  from  the 
deaths  by  the  percentage  which  the  deaths  ^usii- 
ally  are  of  the  cases,  we  find  that  we  can^-  cal- 
culate the  cases  from  one  hundred  deaths  of  scar- 
let fever  (on  the  above  returns)  as  seven  hun- 
dred, two  thousand,  three  hundred  and  fifty,  or 
one  thousand — how  very  valuable  ! 

SUMMARY 

The  vital  statistician  of  the  future  will  be  the 
scientific  manager  of  a  business  department,  for, 
through  the  epidemiologist  working  in  the  field, 
he  will  know  where  the  diseases  are,  not  where 
they  were,  and  he  will  know  which  disease  de- 
mands the  most  attention.  He  will  know  also 
what  resources,  in  men  and  money,  the  health 
department  has,  to  fight  its  battles  with.  The 
correlation  of  these  two  factors  has  seldom  been 
achieved,  rarely  even  attempted,  in  public  health 
circles,  although  in  life  insurance  it  has  long- 
been  known  that  their  inter-relations  were  the 
absolute  sine  qua  non  of  success.  Any  business 
man's  first  step  in  reorganizing  public  health  for 
actual  service  would  necessarily  be  (a)  to  de- 
termine what  requires  to  be  done;  (b)  to  de- 
termine what  there  is  to  do  it  with.     Tlie  max- 

106 


imiim  required  returns  from  the  minimum  nec- 
essary expenditure  should  be  the  only  motto. 
To  secure  this  information,  no  one  but  a  statis- 
tician knowing  statistics,  but  knowing  men  and 
things  as  well  as  figures,  can  succeed.  To  con- 
fine his  work  to  deaths,  even  to  cases,  from  pre- 
ventable diseases,  is  to  study  output  only,  with 
no  regard  to  income.  To  study  income,  as  is  so 
widely  done,  without  regard  to  whether  that  in- 
come is  spent  to  achieve  lessening  of  disease  and 
death  or  merely  for  nuisances  or  smoke  inspec- 
tion, is  simple  madness. 


107 


Chapter  X 
COMMUNITY  DEFENSE  APPLIED 

TUBERCULOSIS    IX    CEXERAL 

Previous  chapters  have  outhned  the  general 
principles  which  govern  modern  pubHc  health 
efforts.  The  present  chapter  will  show  the  spe- 
cific applications  of  these  principles  to  one  specific 
infectious  disease,  namely,  tuberculosis.  This 
disease  is  selected  because  the  same  principles 
that  apply  to  all  other  infectious  diseases  apply  to 
it  and  because  it  is  the  most  important  of  all  the 
diseases  now  recognized  as  really  preventable, 
with  the  exception  of  the  venereal  diseases. 

Tuberculosis,  in  all  forms,  is  due  to  the  growth, 
somewhere  in  the  body,  of  a  certain  germ,  ex- 
actly as  diphtheria  and  typhoid  are  due  to  the 
growth,  in  the  body,  of  certain  germs.  There 
are  many  very  definite  individual  differences,  in 
the  size,  shape,  manner  of  growth,  etc.,  of  the 
three  different  germs  of  these  three  different  dis- 
eases, and  these  differences  make  it  perfectly  pos- 
sible to  distinguish  each  germ  from  the  others, 
just  as  any  farmer  can  distinguish  oats,  corn, 
and  potatoes  from  each  other. 

But  just  as  there  are  dift'erent  varieties  of 
potatoes,  so  there  are  at  least  two  varieties  of 
tuberculosis  germs  which  affect  human  beings. 
One  variety  is  what  is  known  as  the  human  tu- 

108 


berculosis  germ  proper.  The  other  is  found 
chiefly  in  cattle  and  is  therefore  called  the  cattle 
tuberculosis  germ  (the  bovine  tuberculosis 
germ),  and  this  name  is  given  to  this  variety 
even  when  it  is  found  in  the  human,  as  it  some- 
times is. 

HUMAN    TUBERCULOSIS 

A  most  important  difference  that  the  germs  of 
human  tuberculosis,  of  diplitheri^3^d  of  typhoid 
fever  show  amongst  themselves  ^s  not  a  differ- 
ence in  size,  shape,  etc.,  but  in  the  parts  of  the 
body  each  selects.  Thus  the  diphtheria  germ 
flourishes  chiefly  in  the  nose  and  throat ;  the 
typhoid  germ  flourishes  chiefly  in  the  intestine 
and  perhaps  the  blood ;  while  the  human  tuber- 
culosis germ  will  flourish  almost  anywhere  in 
the  body,  glands,  bones,  joints,  intestine,  kidney, 
brain,  lungs.  This  selection  is  no  mere  accident, 
although  we  do  not  know  how  it  comes  about. 
All  three  germs  enter  the  body  chiefly  by  the 
mouth,  conveyed  thereto  chiefly  by  the  hands, 
but  also  more  or  less  through  food  and  milk,  and, 
in  the  case  of  typhoid  fever,  through  water  and 
flies.  On  entering  the  mouth,  all  three  germs, 
which  are  of  course  far  too  small  to  taste  or  feel, 
are  swallowed  in  the  food,  milk,  etc.,  in  which 
they  happen  to  be  present,  or  merely  in  the  saliva; 
if,  as  is  most  usual,  they  reach  the  mouth  di- 
rectly or  indirectly  from  the  fingers.  Once  swal- 
lowed, all  three  pass  into  the  stomach,  where 
many  are  killed  by  the  acid  there  present,  the 
survivors,  if  any,  passing  on  into  the  intestine. 
On  this  journey  from  mouth  to  intestine,  some 
are  left,  of  course,  by  the  wayside,  stranded  on 
the  tonsils,  throat,  gullet,  etc.  Here  at  once  is 
shown  their  respective  peculiarities.  Of  all  the 
diphtheria  germs  that  are  thus  swallowed,  prac- 

109 


tically  only  those  that  are  stranded  in  the  throat, 
will  flourish ;  those  diphtheria  germs  which  pass 
on  into  the  stomach  or  intestine  are  destroyed 
or  pass  out  harmlessly.  On  the  other  hand,  ty- 
phoid germs,  if  stranded  on  the  throat,  do  not 
flourish  there,  nor  do  those  which  reach  the 
stomach  flourish  in  that  organ.  It  is  only  those 
typhoid  germs  which  survive  the  journey  until 
the  intestine  is  entered  that  can  succeed  in  pro- 
ducing typhoid  fever.  The  human  tuberculosis 
germ  has  a  still  longer  road  to  go.  Not  only 
must  it  pass  mouth,  stomach,  and  intestine ; 
also  it  must  be  absorbed  from  the  intestine  into 
the  blood,  as  the  food  is ;  but  it  does  not  grow  in 
the  blood.  The  blood  is  only  a  river,  by  which 
it  can  be  carried  to  a  favorable  developing 
ground.  We  do  not  know  at  all  why  human 
tuberculosis  germs  entering  the  blood  thus, 
should  finally  settle  and  grow  in  a  joint  in  one 
person,  in  a  lung  in  another,  in  a  kidney  or  a 
gland  or  a  bone  in  another.  However,  this  is  the 
way  in  which  these  dififerent  forms  of  human 
tuberculosis  develop.  The  old  idea  that  human 
tuberculosis  of  the  lung  (consumption)  is  con- 
tracted chiefly  by  breathing  the  germs  directly 
into  the  lungs  has  been  definitely  upset.  The 
lungs  are  infected  from  the  blood-stream  chiefly, 
just  as  are  the  other  internal  organs,  bones,  and 
joints. 
y  Another   and,    from   the   public   health   stand- 

point, an  even  more  important  difference  exists. 
Diphtheria  germs  developing  in  the  throat,  and 
typhoid  fever  germs  developing  in  the  intestine, 
can  readily  escape  from  the  body :  in  the  case  of 
diphtheria,  through  the  mouth  and  nose  dis- 
charges ;  in  the  case  of  typhoid  fever  through 
the  bowel,  and  sometimes  the  bladder,  discharges. 

110 


It  is  the  escape  by  these  channels  of  these  germs 
from  the  body  which  makes  these  diseases 
"catching"  or  "infectious"  or  "communicable," 
for  if  they  could  not  escape  from  the  body  they 
could  not  reach  other  persons  and  therefore 
could  not  be  "catching."  But  in  human  tuber- 
culosis, most  of  the  places  where  it  develops, — 
bones,  glands,  joints,  etc.,  —  are  not  connected 
with  any  opening  of  the  body  by  which  the  germs 
may  leave  the  body.  These  forms  of  tuberculosis 
have  no  great  highway  to  the  outside  lying  at 
their  doors  to  carry  the  germs  out  to  other  per- 
sons. Practically  only  in  human  tuberculosis  of 
the  lungs  are  such  highways  provided  for  the 
human  tuberculosis  germs,  although  sometimes  in 
bladder,  kidney,  and  intestinal  tuberculosis.  But 
in  the  latter  forms,  the  germs  do  not,  as  a  rule, 
pass  out  by  the  highways  provided  for  them  in 
such  condition  or  such  numbers  as  to  he  of  serious 
importance  in  propagating  the  disease.  In  human 
lung  tuberculosis,  on  the  other  hand,  the  wind- 
pipe, throat,  and  mouth  form  a  highw.ay,  along 
which  the  germs  may  escape  from  the  afifected 
lung  in  such  enormous  numbers  that  twenty-four 
billion  per  day  have  been  detected  in  the  dis- 
charges (sputum)  from  the  lung  of  a  single  adj 
vanced  case,  although  the  average  number  from 
the  average  case  is  usually  "only"  four  or  five 
billion  daily. 

Thus  it  comes  about  that  human  tube^culosis 
of  the  lungs  is  the  only  common  form  of  human 
tuberculosis  which  is  much  to  be  feared  as  in- 
fections. Practically  all  the  other  forms  of  hu- 
man tuberculosis  are  derived  from  the  sputum 
of  cases  of  human  lung  tuberculosis,  carried 
chiefly  by  mouth-spray  and  on  the  hands,  and  if 
cases  of  human  lung  tuberculosis  did  not  act  to 

111 


spread  infection  to  other  persons,  all   forms  of 
human  tuberculosis  would  quickly  disappear. 

Moreover,  even  human  lung  tuberculosis  is  not 
very  infectious  in  the  early  stages,  i.  e.,  when  the 
germs  are  growing  in  the  lung  tissue,  but  have 
not  yet  reached  the  air-passages,  because,  until 
then,  the  germs  cannot  escape  into  the  windpipe 
and  so  by  the  throat  to  the  mouth.  When  in  the 
later  stages  the  germs  reach  the  air-passages  the 
way  for  the  escape  of  the  germs  to  the  outside 
and  so  to  other  mouths  is  ''open."  Persons  in 
this  stage  of  tuberculosis  are  called  "open"  cases, 
and  it  is  therefore  only  the  ''open"  cases  that  are 
seriously  to  be  feared  as  infectious. 

THE   ABOLITION    OF    CATTLE  TUBERCULOSIS  OF   THE 

HUMAN 

Although  the  cattle  tuberculosis  germ  differs 
from  the  human  tuberculosis  germ  somewhat  in 
size,  shape,  etc.,  the  most  important  public  health 
difference  is  this :  the  cattle  tuberculosis  germ 
seldom  produces  lung  tuberculosis  in  the  human. 
It  produces  bone,  gland,  joint,  etc.,  tuberculosis, 
but  lung  tuberculosis  hardly  ever.  Consider  how 
important  this  fact  is.  It  means  that  cattle  tu- 
berculosis existing  i)i  a  human  can  very  seldom 
he  conveyed  from  that  human  to  another  human. 
In  other  words,  cattle  tuberculosis  may  be  trans- 
mitted from  cattle  to  man,  but  practically  is  not 
further  transmitted  from  man  to  man.  To  pre- 
vent cattle  tuberculosis  in  the  human,  we  do  not 
need  to  take  into  account  existing  cases  of  cattle 
tuberculosis  in  the  human,  but  only  existing  cases 
of  cattle  tuberculosis  in  cattle.  If  we  free  our 
cattle  of  cattle  tuberculosis,  we  shall  free  our 
humans  of  cattle  tuberculosis  also ;  and  this  is  the 
only  practical  way  that  cattle  tuberculosis  in  the 

112 


human  can  be  abolished  unless  and  until  the  hu- 
man race  abandons  the  use  of  cow's  milk  raw. 

THE   ABOLITION    OF    HUMAN    TUBERCULOSIS 

How  can  we  abolish  human  tuberculosis  ?  Ex- 
actly as  we  can,  and  some  day  shall,  abolish  any 
and  all  other  infectious  diseases,  by  killing  off 
the  germ  that  causes  it,  exactly  as  we  have  al- 
most abolished  the  race  of  buffalo  by  killing  off 
the  existing  buffalo.  We  know  well  enough  that 
when  the  last  buffalo  is  dead,  no  man,  however 
wise,  no  government,  however  powerful,  could 
ever  produce  another  buffalo.  So,  once  the  ex- 
isting diphtheria  or  scarlet  fever  or  tuberculosis 
germs  are  all  dead,  thefe  is  no  way  under  heaven 
by  which  these  particular  germs  could  be  pro- 
duced again.  Those  which  exist  now  are  not 
"evolved  from  dirt"  any  more  than  are  buffalo  or 
roses.  Those  which  are  living  today  are  dimply 
the  descendants  of  those  which  existed  yester- 
day and  so  on,  just  as  in  the  case  of  buffalo  or 
roses,  back  to  the  dawn  of  history.  Once  anv 
race  of  plant  or  animal  is  wiped  out,  it  can  never 
be  redeveloped;  and  the  tuberculosis  germ,  just 
as  well  as  the  germs,  of  diphtheria  or  typhoid 
fever,  can  be  abolished  exactly  as  the  mega- 
therium or  dinosaur  has  been  abolished,  i.  e.,  by 
killing  off  the  existing  individuals. 

"But  consider  the  enormous  numbers  and  the 
tiny  size  of  germs  and  that  they  are  present 
everywhere, — in  air,  water,  food,  milk,  dust ;  in 
and  on  everything  we  touch  or  taste  or  handle. 
It  is  quite  impossible  to  kill  them  all." 

True,  germs  are  everywhere  but  not  disease 
germs.  We  know  some  fifteen  hundred  or  more 
species  of  germs  and  hardly  fifty  of  these  pro- 
duce disease,  while  only  two,  already  mentioned, 
produce  tuberculosis  in  the  human.     That  these 

^     113 


g-erms  are  very  small  and  cannot  be  slaughtered 
individually  like  buffalo,  is  true,  but  it  is  also  true 
that  their  very  minuteness  means  that  billions  can 
be  slaughtered  at  a  time,  if  they  are  only  kept 
together.  As  to  tuberculosis  germs  being  every- 
where, all  over,  outdoors  and  indoors — this  is 
not  true.  No  more  important  fact  in  public 
health  has  ever  been  formulated  than  this,  due 
to  that  keen  leader  in  public  health,  Chapin  of 
Providence :  The  germs  that  produce  disease 
are  not  ubiquitous,  not  in  dust  everywhere,  water 
everywhere,  milk  everywhere.  They  are  chiefly, 
almost  wholly,  ///  the  bodies  of  a  relatively  few 
people,  or  animals ;  and  when  they  escape  from 
those  bodies,  where  alone  they  find  the  peculiar 
food,  high  temperature,  abundant  moisture,  and 
darkness  which  they  need,  they  promptly  die  or 
become  harmless.  Even  in  water,  milk,  food, 
etc.,  into  which  they  may  be  introduced  from  in- 
fected persons,  their  lives  are  short,  and  they 
must  quickly  reach  a  new  living  victim,  or  die. 

To  abolish  any  one  race  of  disease  germs  is 
far  easier  than  to  destroy  some  much  larger 
things.  Thus  to  abolish  flies  means  not  only  kill- 
ing all  flies,  indoors  in  all  houses  everywhere,  in 
all  stables  everywhere,  in  and  around  all  dwell- 
ings everywhere,  but  also  throughout  all  fields 
and  forests,  mountains  and  valleys  everywhere, 
because  flies  are  hardy  outdoor  beings  as  well  as 
indoor  beings.  They  can  breed  and  flourish  al- 
most anywhere,  where  any  kind  of  food,  even  in 
vanishing  quantity,  is  to  be  had.  ]\Ioreover,  they 
can  move  of  their  own  volition  with  promptness 
and  despatch,  have  quick  eyes  and  quicker  wings 
to  escape  designing  enemies,  and  in  a  thousand 
ways  can  take  care  of  themselves. 

Disease  germs,    in   contrast   with   the   fly,   are 

114 


very  tiny  and  helpless  particles  of  protoplasm, 
having  no  eyes  to  see  an  enemy,  no  nose  to  smell 
him,  no  means  of  running  away  from  him.  They 
cannot  flourish  on  almost  any  food,  but  need  the 
living  tissues  of  the  human  body ;  they  cannot  grow 
at  almost  any  temperature,  but  must  have  the 
heat  of  the  human  body.  In  brief,  they  are  not 
merely  indoor  plants :  they  are  incubator  plants 
and  cannot  grow,  thrive,  or  reproduce  themselves 
in  nature,  except  in  the  incubators,  our  bodies, 
or,  in  a  few  cases,  animal  bodies,  provide  them. 
Hence  if  we  were  able  to  take  a  visual  census  of 
all  the  living  tuberculosis  or  scarlet  fever  or  diph- 
theria germs  in  the  world  we  should  see  them, 
not  in  the  dust  everywhere,  the  water  every- 
where, the  food  everywhere,  etc.,  but  in  a  very 
few  places  only,  and  those  places  would  be,  in 
almost  all  cases,  the  bodies  of  humans  (or  ani- 
mals). 

Indeed,  we  can  foretell  just  about  what  the 
census  of  tuberculosis  germs  in  any  district  of 
the  temperate  zone,  would  show.  It  would  show 
about  one  person  .in  every  seven,  hundred  of 
the  population  carrying  a  large  number  of  active, 
living,  growing  germs  in  the  lungs, — germs  that 
were  escaping  to  the  outside  and  reaching  other 
persons'  mouths.  It  would  show  also  a  number 
of  other  persons  in  whom  the  germs  were  pres- 
ent in  joints,  bones,  glands,  etc.,  but  not  escaping 
to  others ;  and  it  would  show  a  number  of  per- 
sons affected  in  the  lungs,  and,  later,  likely  to 
develop  to  the  point  where  the  germs  could 
escape,  but  practically  harmless  to  others  so  far. 
Beyond  this,  hunt  high,  hunt  low,  search  gar- 
bage barrels,  manure  heaps,  dead  animals,  dusty 
streets,  sewage,  water,  foods,  milk,  etc.,  and 
human  tuberculosis  germs,  alive,  growing,  capa- 

115 


ble  of  producing  the  disease,  zvoiild  not  be  found 
True,  in  the  immediate  neighborhood  of  th(! 
''open"  cases  the  sputum  they  throw  out,  their 
mouth-spray,  and  their  hands  would  show  the 
germs,  and  things  they  spit  into,  mouth-spray 
into,  or  touch,  would  show  for  a  short  time  a 
few ;  but  these  would  be  dying  or  already  dead, 
holding  out  danger  to  other  persons  only  during 
the  short  time  which  elapses  between  leaving 
their  happy  homes  in  the  human  lung  and  death 
outside  from  drying  and  starvation.  This  ap- 
plies, not  to  tuberculosis  germs  alone,  but  prac- 
tically to  all  the  germs  of  the  ordinary  infectious 
diseases,  anthrax  and  tetanus  forming  two  chief 
exceptions,  both  rare  diseases  here. 

No  person  enei'getic  enoiigJi  to  advocate  the 
abolition  of  the  fly  should  Jiesitate  a  moment  to 
advocate  the  far  simpler,  smaller,  easier,  and  far 
more  important  zvork  of  abolishing  those  germ:: 
that  alone  can  make  the  Hy  a  danger. 

In  brief,  the  method,  and,  I  believe,  the  only 
rapid,  complete,  effectual  method  of  abolishing 
human  tuberculosis,  is  this :  find  the  ''open''  cases 
and  prevent  the  spread  from  them  of  the  germs 
they  alone  throw  out  in  numbers  and  condition 
to  be  feared.  That  means,  find  the  one  person 
in  every  seven  hundred  whose  infection  threatens 
all  the  rest,  and  supervise  him  just  enough  to 
keep  his  discharges  from  entering  other  people's 
mouths. 

How  is  this  one  person  in  every  seven  hundred 
to  be  found?  Not  without  hunting,  not  without 
ingenious,  skillful,  deliberate,  sagacious,  well- 
trained  hunters,  epidemiologists  as  devoted  and 
persistent  in  their  work  as  the  average  insurance 
agent  is  in  his, — men  who  devote  themselves  to 

116 


the  abolition  of  tuberculosis  as  whole-heartediv 
as  any  merchant  does  to  making  money. 

And  how  ?  Where  shall  we  begin  ?  Must  we 
canvass  the  whole  population  one  by  one?  True, 
that  would  do  it,  but  epidemiology  has  found  a 
simpler,  keener,  more  scientific,  far  more  eco- 
nomic plan,  illustrated  for  typhoid  fever  in  a 
previous  chapter.  Begin  with  the  known  cases 
and  search  the  zones  of  infection  surrounding 
each  for  mild,  unrecognized,  and  concealed  cases. 
(In  tuberculosis  the  search  for  carriers  is  prolDa- 
bly  unnecessary,  certainly  at  the  present  .time.) 

"But  why  not  concentrate  on  the  incipient  lung 
case,  the  case  that  may  be  cured,  and  by  prevent- 
ing this  case  from  going  on  to  the  "open"  in- 
fectious stage  get  rid  of  danger  to  others  thus, 
instead  of  by  attention  to  the  open  case?" 

For  several  reasons,  the  abolition  gf  tubercu- 
losis through  care  of  incipient  lung,  cases  only 
cannot  at  present  be  accomplished. 

1st.  Because  incipient  cases,  in  the  truly  in- 
cipient "non-open"  stage,  are  discovered,  pei*- 
haps  are  discoverable,  in  a  very  small  percentage 
only  of  their  total  number. 

2nd.  Because  a  large  proportion  of  the  in- 
cipients  so  found  would  not  go  on  in  any  case. 
whether  found  or  not,  to  the  open  stage ;  and 
the  time  and  money  and  efforts  spent  in  finding 
and  supervising  them  would  have  been  relatively 
wasted. 

3rd.  Because  a  certain  proportion  of  the  in- 
cipients  so  found  would  go  on,  in  any  case,  to  the 
open  stage,  and  thus  become  infectious  cases, 
despite  all  efforts.  In  these  alone  would  the  ef- 
forts expended  be  of  service  in  preventing  new 
cases.    The  trouble  is  that,  in  the  incipient  stage, 

117 


it  could  not  be  determined  whether  or  not  the 
case  would  so  develop. 

4th.  Because  the  time  and  attention  devoted 
to  incipients,  to  prevent  them  becoming  open 
cases,  would  imply,  as  it  has,  alas,  so  far  im- 
plied, neglect  of  the  advanced  ''open"  cases,  in 
which  the  danger  of  infection  is  so  immensely 
greater. 

5th.  Because  if  all  the  incipient  cases  were 
discovered  they  would  form  a  mass  of  persons 
so  great  as  to  be  beyond  handling  properly  by 
any  at  present  even  dreamed  of  force  of  attend- 
ants, etc.  If,  as  at  present,  only  a  very  small 
proportion  were  found  the  actual  situation  would 
not  be  materially  changed. 

''Would  you  then  cease  the  care  of  incipient 
cases  in  sanatoria,  and  concentrate  wholly  on  the 
advanced  case?" 

No.  First,  because  the  tuberculosis  sanatoria,  in- 
tended though  they  are  for  incipient  cases,  really 
handle  very  many  "open"  cases,  and  to  that  ex- 
tent prevent  new  infections ;  secondly,  because 
the  tuberculosis  sanatoria  do,  in  a  measure,  fulfill 
their  proper  function  of  cure  for  incipients  and 
even  early  "open"  cases  to  some  extent  and  hence 
save  life.  But  as  a  means  of  abolishing  tubercu- 
losis, the  ordinary  tuberculosis  sanatorium  for 
incipient  cases  is  quite  hopeless. 

The  thing  to  do  first  is,  find  the  recognized 
"open"  cases,  whether  they  be  in  early,  advanced, 
or  late  stages,  and  place  them  where  they  can 
spread  the  disease  no  further.  Then  search  the 
"zones  of  infection"  surrounding  them,  i.  e.,  their 
relatives  and  associates,  for  mild,  unrecognized 
or  concealed  cases,  and  also  for  incipients,  han- 
dling all  "open"  infectious  cases  thus  found,  in 
the  same  manner.     This  system  would  begin  at 

118 


the  right  end  by  stopping  further  infections,  and 
would  incidentally  find  those  early  "open"  and 
'*non-open"  incipient  cases  wherein  sanatorium 
treatment  would  be  of  most^avail. 

SUMMARY 

Tuberculosis  is  a  typical  infectious  disease,  and 
it  must  be  handled  on  the  same  .principles  as  any 
other  infectious  disease ;  hence,  by  blocking  the 
routes   of   infection,   but   chiefly   by   finding  the  , 
sources  and  preventing  spread  thence. 

Of  the  five  great  routes  of  infection, — water, 
food,  flies,  milk,  and  contact, — human  tubercu- 
losis travels  chiefly  by  contact,  through  sputum, 
mouth-spray,  and  hands,  directly,  or  almost  di- 
rectly, from  patient  to  prospective  patient.  Prac- 
tically, it  is  spread  exactly  as  scarlet  fever  or 
diphtheria  is  spread.  Public  flies  and  public  food 
supplies  are  comparatively  insignificant  convey.- 
ors.  Public  water  supplies  are  almost  negligible, 
and  public  milk  supplies  act  chiefly  in  conveying- 
cattle  tuberculosis  to  man,  although,  if  the  milk 
be  handled  by  tuberculous  humans,  it  may  con- 
vey human  tuberculosis  also.. 

It  is  evident,  then,  that  blocking  of  the  routes, 
since  the  chief  one  is  contact,  involves  chiefly  the 
far  more  important  measure  of  finding  the  source, 
just  as  in  scarlet  fever,  or  diphtheria,  and  if 
these  sources  are  found  and  prevented  from  gain- 
ing access  to  the  routes,  the  routes  may  be  disre- 
garded. The  measures  for  finding  the  human 
sources,  practically  the  "open"  cases  of  lung  tu- 
berculosis in  the  human,  are  epidemiological  and 
have  already  been  discussed  in  principle  before 
(Chapter  V.) 

The  measures  necessary  for  finding  the  animal 
sources    (infected    milch    cows)    are    the    well- 

119 


known  tuberculin  test  of  herds,  with  proper  re- 
petitions, and  the  eHmination  of  the  tuberculous 
animals.  Serious  enough  as  cattle  tuberculosis 
in  the  human  is,  its  prevalence,  nevertheless,  is 
much  less  than  that  of  human  tuberculosis  and 
its  infectiveness  in  the  human  is  nearly  negligi- 
ble. Hence,  if  our  efforts  were  concentrated 
wholly  on  human  tuberculosis,  more  cases  and 
more  deaths  would  be  prevented  in  one  year's 
work,  than  efforts  on  bovine  tuberculosis,  how- 
ever successful,  could  possibly  achieve  in  many 
vears. 


120 


Chapter  XI 

THE  CONCLUSION  OF  THE  WHOLE 
MATTER. 

THE  DOING  OF  IT 

If  previous  chapters  have  succeeded  in  the  very 
earnest  attempt  they  made  to  show  what  the  new 
pubHc  health  principles  are  and  how  they  have 
become  established,  the  one  momentous  matter 
in  public  health  still  left  unsolved  is  this — why, 
why,  why  are  not  these  principles  observed?  If 
we  know  how  to  do  it,  why  is  it  not  done  ? 

Chiefly,  because  the  general  public  does  not 
know.  They  still  believe  religiously  the  theories 
that  were  beginning  to  be  discarded  in  scientific 
circles  twenty  years  ago.  ,  To  any  one  who  has 
discussed  these  subjects  before  lay  audiences  it 
becomes  most  evident  that  people  the  most  re- 
fined and  educated  still  believe,  concerning  pub- 
lic health,  almost  the  same  things  that  the  most 
ignorant  hold.  So  long  as  these  beliefs  control 
public  opinion,  so  long  will  public  health  lag  far 
behind  other  advances.  Four  of  the  most  com- 
mon fallacies  the  writer's  experience  of  public 
discussion  has  elicited  are  illustrated  here,  and 
the  reader  may  easily  test  his  own  state  of  knowl- 
edge by  asking  himself  what  answers  he  would 
give  to  the  questions  here  presented : 

THE    CHIEF,  OBJECTIONS. 

1.  If  the  disease  germs  are  not  evolved  afresh 
from  dirt  or  decomposi,tion,  but  are  descendants 
of  their  forefathers,  where  did  the  first  disease 
germ  come  from? 

121 


We  do  not  know.  Where  did  the  first  wheat 
come  from?  Or  the  first  horse?  We  know  that 
we  can  ^ret  no  wheat  iiozv,  except  from  wheat, 
nor  horses  except  from  horses.  These  germs  arc 
plants  or  animals,  exactly  as  wheat  or  horses  are. 
That  they  are  tiny  no  more  changes  this  law  of 
descent  than  does  the  enormous  size  of  a  whale 
or  of  a  redwood  tree.  "All  life  from  life"  holds 
true  in  nature  through  the  whole  scale,  from 
germ  to  human  beings.  Besides,  under  the  mi- 
croscope, we  see  the  germs  ''descending"  from 
their  forefathers. 

2.  If  dirt  does  not  breed  disease,  then  why 
are  dirty  people  so  subject  to  disease? 

Dirty  people  are  no  more  subject  to  disease 
than  clean.  Infection,  if  it  reaches  either,  may 
yield  disease  in  either ;  if  it  reaches  neither, 
neither  will  suffer.  If  an  infectious  disease  en- 
ters a  household,  the  dirtiest  people  will  not 
spread  it,  despite  their  dirty  habits,  if  they  avoid 
the  one  specific  ''dirt''  (the  discharges  of  the  pa- 
tient) which  alone  is  harmful;  the  cleanest  peo- 
ple wnll  not  fail  to  catch  it  if,  in  their  general 
cleanliness,  they  neglect  that  same  specific  ''dirt." 
True,  dirt,  carelessness  and  disorder  offer  some 
indication  whether  or  not  the  people  who 
show  these  characteristics  would  have  the  sense, 
or  take  the  trouble,  to  avoid  the  one  dangerous 
"dirt,"  should  it  appear.  On  the  other  hand, 
cleanliness,  thrift,  and  system  indicate  characters 
likely  to  handle  infectious  "dirt"  with  the  same 
care  they  show  in  other  matters.  But  the  dir- 
tiest people  who  make  the  proper  efforts  to  avoid 
infection  can  and  do  many  times  escape, 'remain- 
ing as  dirty  as  they  please  in  other -ways.  The 
cleanest  people  wdio  neglect  or  do  not  know  the 
methods  can  and  do  suffer. 

122 


3.  If  you  tell  people  "dirt"  does  not  breed  dis- 
ease, you  are  praising-  dirt  —  upsetting  all  the 
careful  uplift  all  the  best  people  have  attempted 
for  many,  many  years. 

Suppose  a  zvater-pipe  is  leaking  in  your  house, 
flooding  the  floors  and  damaging  everything. 
Suppose  that  when  the  plumber  is  hurried  to  the 
rescue,  he  tests  the  ^a^-pipes,  finds  a  leak,  stops 
it,  and  tells  you  all  is  well.  What  would  you 
say  ?  True,  the  gas  leaked ;  it  was  right  to  stop 
it :  but  the  zuater  goes  flowing  on !  Suppose  to 
your  objections  he  replies:  "But  think  how  bad 
the  effect  would  be  on  our  campaign  against  gas- 
leaks,  if  we  failed  to  urge  that  gas-leaks  must  be 
stopped,  whether  that  stop  the  water-leaks  or 
not.  If  I  admit  that  gas-leaks  have  no  con- 
nection with  water-leaks,  you  would  let  the 
gas  flow  on.  I  must  make  you  believe  the  wa- 
ter-leak depends  on  the  gas-leak,  else  you  won't 
fix  the  ^as-leak."  Stopping  gas-leaks  cannot  help 
water-leaks  nor  vice  versa.  Reducing  disease 
will  not  make  people  "clean,"  nor  will  making 
people  "clean"  reduce  diseatse ;  only  the  one 
"cleanliness"  of  avoiding  infected  discharges  will 
gain  this  end. 

4.  Why  do  you  talk  so  much  about  disease? 
Teach  healthy  living,  keep  the  body  strong,  well 
clothed,    well   fed,   and  you   need  not   fear-dis-: 
ease,  especially  infectious  disease,  at  all^ 

This  is  a-  fallacy  so  widespread  that  even  phy- 
sicians teach  it,,  in  good  faith,  without  consider- 
ing that  they  themselves  would  never-  let  their 
own  children,  be  they  never  so  healthy,  run  with 
a  measles  c^se,  or  mumps,  or  scarlet  fever,  un- 
less their  children  had  had  the  disease  before. 
If  the  teaching  is  not  good  enough  for  practical 

128 


application  to  physicians'  children,  it  is  not  good 
enough  for  public  health. 

You  see,  everyone  knows  that  children  who 
have  had  measles  very  seldom  take  it  a  second 
time,  and  this  without  regard  to  whether  they 
are  robust  or  sickly,  healthy  or  weak.  Every- 
one knows,  too,  that  children,  healthy  or  sickly, 
who  have  not  yet  had  measles,  almost  invariably 
catch  it  if  they  are  exposed.  Practically,  the 
same  is  true  of  scarlet  fever,  mumps,  whooping 
cough,  smallpox,  chickenpox,  etc.  It  is  not  so 
-^  true  of  tuberculasis^  diphtheria,  or  typhoid,  since 
'  those  who  have  had  tuberculosis,  diphtheria,  or 
typhoid  may  get  it  again ;  although  again  with- 
out regard  to  whether  they  are  healthy  or  sickly.' 
In  measles  and  the  other  diseases  like  it,  per- 
sons exposed  w^ho  do  not  contract  the  disease, 
escape,  not  from  good  health,  but  just  because 
they  have  within  their  bodies  a  certain  antidote 
to  the  particular  poison  of  that  particular  dis- 
ease, x^nyone  can  prove  this  to  himself,  if  he 
will  think  a  moment.  If  general  good  health 
really  did  protect  against  these  diseases,  a  child 
who  could  not  catch  measles,  because  pro- 
tected by  his  general  good  healthy  could  not  catch 
scarlet  fever,  either,  for  the  same  general  health 
would  save  him  from  them  both.  But  everyone 
knows  that  the  child  who  cannot  catch  measles 
(because  he  has  had  it)  must  nevertheless  be 
guarded  from  scarlet  fever,  unless  he  has  had 
that  too.  In  brief,  an  attack  of  these  diseases 
gives,  in  most  persons,  an  immunity ;  that  is,  an 
antidote  is  formed,  which  then  protects  them 
from  having  it  again.  But  there  is  a  different 
antidote  for  each  disease.  Having  had  measles 
once  is  excellent  protection  against  measles,  but 

124 


it  is  no  protection  at  all  against  scarlet  fever  or 
mumps  or  any  other  illness. 

In  diphtheria  an  antidote  is  formed,  but  often 
disappears  again,  and  therefore  tjiis  disease  may 
be  suffered  more  than  once.  In  typhoid  also  an 
antidote  is  formed  lasting  a  year  or  two.  We 
know  and  are  learning  more  of  this  antidote 
against  typhoid.  We  do  not  know  yet  much 
about  that  which  perhaps  protects  against  tuber- 
culosis. 

Now,  no  one  dreams  that  the  antidote  for 
measles  can  be  developed  by  diet,  exercise,  or 
clothing;  by  fresh  air,  drugs,  or  anything  in 
fact,  except  by  suffering  an  attack  from  the 
measles  germ.  Nor  can  anyone  seriously  be- 
lieve that  the  antidotes  for  typhoid,  or  chicken- 
pox,  etc.  (except  that  for  smallpox  vaccination 
takes  the  place  of  an  attack  of  smallpox)  can  be 
developed  except  by  equivalent  means.  If  "good 
health"  will  not  protect  against  any  of  these 
diseases,  taken  one  by  one,  how  can  "good  health" 
protect  against  all  of  them  taken  together? 

So  we  might  deal  with  fallacy  after  fallacy, 
all  based,  however,  on  two. 

POPULAR   FALLACIES 

The  first  of  these  is  that  infectious  disea,ses 
come  from  "general  bad  surroundings."  The 
truth  is  that  they  come  solely  from  certain  germs 
growing  in  the  body,  and  practically  the  only 
sort  of  "bad  surroundings"  which  cause  infec- 
tions is  association  with  one  of  these  infected 
bodies  or  with  its  discharges. 

The  second  great  basic  fallacy  is  this,  that 
"sreneral  good  health"  protects  against  infection. 
The  truth  is,  that  the  only  true  protections 
against  germs  we  know  are,  first  and  best,  to 

\ 
125' 


keep  them  out  of  the  body ;  and,  second,  to  have 
within  the  body  the  special  antidote  for  each 
particular  germ.  We  vaccinate  against  small- 
pox, but  that  does  not  save  us  from  tvphoid 
fever.  A\'e  vaccinate  against  typhoid  fever,  but 
that  does  not  save  us  from  smallpox.  If  we 
could  vaccinate  against  every  disease  (as  per- 
haps some  day  we  shall  be  able  to  do)  we  would 
be  safe,  despite  the  germs,  at  least  while  the 
protection  lasted,  and  after  that  we  could  vac- 
cinate again. 

But  how  much  better  to  avoid  the  germs,  which 
means  avoiding  the  persons  in  whom  thev  are ; 
and  then  we  would  never  need  any  sort  of  vac- 
cination !  * 

Surely,  the  thing  to  do  for  one's  own  sake, 
and  still  more  for  the  sake  of  our  associates,  is 
to  find  the  infected  persons,  or  animals,  that  alone 
can  cause  disease  in  the  true  sense,  and  keep 
them  so  protected  while  the  danger  lasts  that 
they  will  do  no  harm.  Then,  when  their  stock 
of  germs  is  dead  and  done  with,  remove  all  the 
restrictions. 

NEW    FASHIONED    QUARANTINE. 

You  will  say  that  that  is  only  old-fashioned 
quarantine.  It  is,  in  principle,  but  modern  prap- 
tice  changes  it  so  completely  that,  practically 
speaking,  new-fashioned  quarantine  differs  from 
old  as  much  as  motor  cars  difiFer  from  camels. 
In  the  first  place,  old-fashioned  quarantine  did 
not  pick  out  all  dangerous  persons,  but  took  the 
sick  who  form  but  part  of  the  infected,  and  also 
took  the  well  who  were  found  with  the  sick, 
including  thus  some  who  were  not  infected,  and 
kept  all  these  pracncally  in  prison,  in  their  homes, 
or   ships,   or   wherever   else   they   were   staying. 

12G 


Thus,  not  alone  were  many  infected  persons 
overlooked  and  many  uninfected  persons  wrong- 
ly held,  but  also  the  disease  spread  oftentimes 
from  those  infected  who  were  in  the  net  to  tHe 
uninfected  who  were  kept  in  with  th^i,  so  that 
old-fashioned  quarantine,  while  it  protected  the 
community  but  partially,  meant  often  poverty, 
disease,  and  death  to  those  caught  in  its  toils. 
No  wonder  the  very  name  of  quarantine  makes 
many 'people  shudder. 

New-fashioned  quarantine  is  not  a  blanket 
method,  blunderingly  catching  in  its  blindfold 
grip  both  sick  and  well,  the  harmless  and  the 
harmful,  indiscriminately.  New-fashioned  quar- 
antine requires  definite  detailed  knowledge  ap- 
plied with  care  and  patience,  not  mere  force. 

Now,  everyone  wishes  infectious  persons 
handled  so  that  infection  ceases.  Even  the  in- 
fectious do  not  wish  to  spread  their  own  infec- 
tion. The  thing  that  chafes  and  riles  the  aver- 
age person  is  not  restriction  but  unjust  restric- 
tion ;  either  restriction  of  non-dangerous  persons, 
or  restriction  of  some  of  the  dangerou?  only  while 
others  just  as  dangerous  go  free. 

No  mother  minds  the  exclusion  of  her  infec-. 
tious  child  from  public  school,  if  her  neighbor's 
infectious  child  is  excluded  also.     Every  physi- 
cian would  report  his  cases  if  every  other  physi- 
cian did  so  too. 

Here  then  is  the  solution,  based  on  human 
nature,  on  common  sens^,  and  on  the  most  scien- 
tific knowledge.  Find,  through  the  methods  of 
epidemiology,  of  the  laboratory,  and  of  the  vital 
statistician,  skilfully  combined  by  experts,  these 
dangerous  persons,  whether  sick  or  well — these 
only  dangerous  persons,  those  who  carry  on  them 
or  in   them,   germs  of  infectious   diseases.     Set 

127 


all  others  free,  but  keep  these  persons,  not  in 
old-fashioned  quarantine,  but  under  such  con- 
trol that  their  discharges  will  not  pass  to  others ; 
and  do  not  measure  the  length  of  that  control  by 
fixed  time  limits,  blind  and  unjust  as  quarantine 
itself,  but  measure  it  wholly  by  the  length  of  time 
the  germs  remain  in  or  on  the  body.  The  moment 
that  the  germs' have  left  those  persons  they  are 
no  longer  harmful  and  they  should  be  freed. 

To  do  this  properly  means  intimate  attention 
and  supervision  of  infectious  persons  by  men 
who  know  their  business  and  do  nothing  else. 
If  one  such  man  to  every  20,000  persons  began, 
tomorrow,  everywhere,  his  work,  infectious 
diseases  in  ten  3'ears  would  have  vanished  and 
would  have  become  mere  history. 

SUMMARY. 

This,  then,  is  the  conclusion.  The  old  ideas 
have  passed ;  the  new  are  no  longer  theories  but 
facts ;  the  methods  they  require  are  not  untried ; 
they  have  been  practiced  for  years  in  Minnesota. 
The  details  are  worked  out,  the  field  is  ready, 
the  scope  and  cost  are  known.  All  that  remains 
is  to  apply  the  methods  developed  in  this  state 
to  all  infections,  thus  wiping  them  all  out,  once 
and  for  all.  The  way  is  clear,  what  remains  is 
to  follow  it ;  the  method  is  known,  what  remains 
is  to  carry  it  out ;  the  thing  we,  as  a  race  for 
centuries  have  prayed  for,  can  be  done;  all  that 
remains  is  to  do  it. 

Each  generation  of  Minnesotans  pays  now  for 
infectious  disease*  two  hundred  million  dollars 
at  the  least,  and  lias  the  diseases,  too!  \\\\\  not 
pay  one-tenth  this  sum  and  rid  ourselves  of  all 
of  them  forever? 


128 


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